FROZEN    SECTIONS 


OF    A 


CHILD 


BY 


THOMAS     DWIGHT,    M.D. 

INSTRUCTOR    IN   TOPOGRAPHICAL   ANATOMY   AND  HISTOLOGY   IN   HARVARD    UNIVERSITY  ;     FELLOW  OF  THE    AMERICAN     ACADEMY 
OF  ARTS   AND   SCIENCES  ;    SURGEON   AT   THE   CARNEY   HOSPITAL 


FIFTEEN   DRAWINGS    FROM   NATURE 


BY 

H.    P.    QUINCY,    M.D. 


NEW   YORK 

WILLIAM     WOOD    &    COMPANY 
1881 


BIOLOGY 

LIBRARY 

6 


COPYRIGHT 

WILLIAM  WOOD   &  COMPANY 
1881 


TROW'S 

PKINTING  AND  BOOKBINDING  COMPANY 
201-213  Kan  iitA  Street 

NEW   YORK 


PREFACE. 


r  I  ^HE  sections  that  form  the  basis  of  this  little  work  were  made, 
with  many  others,  during  the  winter  of  1 880-81,  to  illustrate  my 
lectures  at  the  Harvard  Medical  School.  The  sections  were  so  in- 
structive, and  the  series  so  perfect,  that  I  was  very  anxious  to  have 
them  drawn  and  published.  The  subject  was  the  body  of  a  girl,  said 
to  be  three  years  old.  The  length  was  thirty-three  inches.  At  this 
age  the  proportions  of  the  body,  and  of  the  organs,  are  no  longer 
those  of  the  infant,  and  not  yet  those  of  the  adult.  The  anatomy  of 
this,  age  has  received  little  attention,  and  I  hope  that  this  work  may 
therefore  be  of  use.  It  will  serve,  also,  for  the  study  of  the  adult 
relations,  as  the  peculiarities  due  to  the  age  of  the  subject  are  care- 
fully noticed  in  the  text.  I  have  endeavored  to  call  attention  to  the 
most  important  inferences  to  be  drawn  from  the  plates,  and  have 
mentioned,  incidentally,  many  points  of  anatomy  which  the  student  will 
not  find  in  the  text-books.  The  reader  is  urged,  however,  to  study 
the  plates  carefully  for  himself.  They  are  of  life-size,  and  drawn 
from  the  sections  with  great  care  and  patience.  The  arteries  were 
injected. 

Believing,  as  I  do,  that  frozen  sections  will  play  an  important  part 
in  the  anatomical  teaching  of  the  future,  I  shall  say  nothing  of  their 


iv  Preface. 

advantages,  which  speak  for  themselves,  but  will  mention  some  of 
their  shortcomings.  One  would  expect  that  they  would  be  very  well 
suited  for  the  study  of  fascise ;  and  so  they  are  if  you  destroy  the 
specimen  by  removing  the  tissues  between  the  fascise.  Otherwise 
you  see  little  or  nothing  of  them,  for  few  fasciae  are  thick  enough  to 
be  easily  distinguished  when  seen  in~  section.  Small  vessels  that 
have  not  been  injected — the  thoracic  duct,  for  instance,  and  nerves 
that  are  cut  across — are  often  made  out  only  with  great  difficulty.  I 
feel  it  my  duty  to  admit  that  there  is  serious  doubt  whether  in  all  the 
plates  the  pneumogastrics  and  the  thoracic  duct  are  placed  quite 
accurately  in  the  posterior  mediastinum. 

My  experience  with  frozen  sections  enables  me  to  offer  the  fol- 
lowing directions  for  making  them.  First,  be  very  sure  that  the  body, 
or  part,  to  be  frozen  is  in  precisely  the  position  you  desire,  and  that 
there  are  no  folds  or  indentations  in  the  skin.  I  always  use  natural 
cold  when  possible.  Weather  much  above  zero  (Fahrenheit)  is  un- 
satisfactory ;  but  if  the  part  is  thoroughly  chilled  by  several  days'  ex- 
posure to  a  pretty  low  temperature,  a  night  of  10°  may  possibly  finish 
it.  Salt  and  ice,  or  snow,  no  doubt,  will  answer  the  purpose,  but 
much  time  and  patience  are  required.  It  is  essential  that  the  melted 
ice  should  have  a  chance  to  run  off.  The  body  should  be  frozen  like 
a  rock — so  much  so  that  the  operator  cannot  tell  whether  he  is  cut- 
ting bone  or  muscle.  Tooth  is  the  only  tissue  he  should  be  able  to 
recognize.  The  sections  should  be  made  in  a  cold  room,  with  a  very 
sharp  saw  that  has  been  chilled.  When  a  section  is  cut,  its  surface 
is  obscured  by  a  thick  half- frozen  saw-dust,  which  is  doubly  thick 
if  the  freezing  is  not  quite  sufficient.  It  is  wisest,  if  time  allows, 
to  remove  this  at  once,  which  is  done  by  pouring  a  little  hot  water 


Preface.  v 

over  the  section  and  brushing  or  scraping  it  off  rapidly  and  carefully. 
This  is  a  very  delicate  part  of  the  process,  and  its  successful  perform- 
ance has  much  to  do  with  the  beauty  of  the  specimen.  If  it  is  to  be 
kept,  it  should  be  laid  on  a  piece  of  glass  or  wood,  and  placed  at  once, 
while  still  frozen,  in  cold  alcohol. 

The  specimens  from  which  these  plates  are  made  are  preserved 
at  the  Harvard  Medical  School,  and  are  at  hand  to  solve  any  doubts 
that  may  arise. 

To  study  the  plates  turn  the  book  so  that  the  vertebra  is  nearest 
to  you  and  imagine  that  you  are  looking  down  into  your  own  body. 

70  BEACON  STREET,  BOSTON, 
July,  1 88 1. 


«kp 


PLATE  I. 

THE  plane  of  this  section  inclines  somewhat  forward.  The  limits 
of  the  neck  are  not  easily  defined :  for,  in  front,  the  upper  part 
is  hidden  by  the  lower  half  of  the  face,  and  behind,  the  lower  part 
of  the  neck  is  indistinguishable  from  the  back.  Thus,  there  is  but  a 
very  small  part  of  the  body  that  is  clearly  neck  and  nothing  else,  and 
this  condition  is  particularly  marked  in  infancy  and  early  childhood. 
The  cut  passes  through  the  body  of  the  sixth  cervical  vertebra,  strik- 
ing it  in  front  near  its  upper  border,  where  it  is  still  cartilaginous. 
The  articular  processes  of  the  fifth  cervical  are  seen  resting  against 
those  of  the  sixth.  The  essential  centres  of  ossification  of  a  vertebra 
are  one  for  the  body  and  one  for  each  half  of  the  arch.  They  are 
separated  by  the  neuro-central  sutures.  The  direction  of  these  sutures 
is  modified  by  the  presence  of  a  double  transverse  process  in  the  cer- 
vical region.  A  more  correct  idea  of  them  is  obtained  from  PLATE  V., 
where  they  cut  off  merely  the  posterior  angles  of  the  body.  They 
disappear  from  the  fourth  to  the  sixth  year.  A  glance  at  PLATE  X. 
will  show  that  ossification  is  completed  sooner  in  the  lower  part  of 
the  column.  The  vertebral  artery  is  seen  in  its  foramen.  In  front  of 
it  is  the  projection  known  as  the  tubercle  of  Chassaignac,  which  is  a 
characteristic  of  die  sixth  vertebra,  and  sometimes  used  as  a  guide 
to  the  carotid. 

The  intervertebral  discs  form  41.9  per  cent,  of  the  length  of  the 
cervical  region  of  the  adult  spine,  the  mean  length  of  this  region  be- 
ing 13.6  ctm.  It  forms  22.5  per  cent,  of  the  length  of  the  column  above 
the  sacrum.  In  the  very  young  embryo,  the  neck  forms  one-third 
of  the  spinal  column  (above  the  sacrum)  and  the  lumbar  region  one- 
fifth.  In  the  adult  these  proportions  are  pretty  nearly  reversed.  This 
change  begins  very  early,  for  at  birth  the  lumbar  region  is  longer  than 
the  cervical.  At  three  years  the  proportionate  length  of  the  cervical 
region  is  a  little  greater  and  that  of  the  lumbar  a  little  less  than  in 


: ;  Frozen  Sections  of  a  Child. 

the  adult.1  The  shortness  of  the  neck  in  infancy  does  not,  therefore, 
depend  on  that  of  the  cervical  region  of  the  spine,  but  on  the  large- 
ness of  the  head,  the  high  position  of  the  sternum,  and  the  abun- 
dance of  fat. 

The  sixth  cervical  nerve  is  seen  leaving  the  spinal  canal,  which 
is  broad  to  contain  the  cervical  enlargement.  It  is  well  to  remember, 
that  as  there  are  eight  cervical  nerves  and  only  seven  vertebrae, 
each  of  the  first  seven  passes  above  the  vertebra  of  the  correspond- 
ing number,  and  in  the  other  regions  the  nerve  passes  under  its  ver- 
tebra. The  nerves  do  not  arise  from  the  cord  opposite  their  points 
of  exit,  but  somewhat  higher ;  suffice  it  to  say,  for  the  cervical  region, 
that  the  eight  nerves  are  all  given  off  above  the  fifth,  or  certainly  the 
sixth,  spine,  which  is  about  on  a  level  with  the  body  of  its  vertebra. 
The  fifth  nerve  and  a  branch  of  the  fourth  are  seen  between  the 
scalenus  anticus  and  medius  on  their  way  to  the  brachial  plexus.  The 
phrenic  is  just  in  front  of  the  former  muscle,  which  it  follows  down  to 
the  thorax.  This  nerve  arises  from  the  fourth  cervical,  but  almost  al- 
ways receives  fibres  from  the  fifth,  though  at  very  uncertain  points. 

The  trachea  is  divided  a  little  below  the  cricoid,  probably  through 
the  first  ring.  This,  therefore,  is  the  important  region  of  trache- 
otomy. The  isthmus  of  the  thyroid  appears  to  be  rather  large  ; 
usually  it  covers  the  three  rings  after  the  first,2  but  it  is  extremely 
variable,  and  may  be  wanting.  The  left  lobe  reaches  to  the  oesopha- 
gus, and  slightly  overlaps  the  carotid.  It  is  easy  to  see  how,  if  en- 
larged, it  might  make  its  way  between  the  artery  and  the  vein,  as  is 
said  sometimes  to  be  the  case.  The  oesophagus,  cut  just  below  its 
origin,  already  inclines  to  the  left.  The  recurrent  laryngeal  nerves 
lie  in  the  angles  between  it  and  the  trachea. 

The  muscular  masses  and  the  general  arrangement  of  the  fasciae 
are  easily  understood.  The  superficial  muscular  layer,  omitting  the 
platysma,  consists  of  the  sterno-mastoids  and  the  trapezii.  They  are 
both  supplied  by  the  spinal-accessory  nerve,  with  some  assistance 
from  the  spinal  nerves.  It  is  a  mistake  to  suppose  that  the  sterno- 
mastoids  bow  the  head.  As  they  are  attached  behind  the  transverse 
axis  of  the  occipital  joints,  they  would  tend  to  throw  the  face  upward. 
The  action  of  one  of  them  is  to  turn  the  face  to  the  other  side.  Thev 


1  Aeby  :  Archiv.  fur  Anatomic  und  Entwickelungsgeschichte,  1879. 

2  Pilcher  :  Annals  of  Anatomy  and  Surgery,  April,  1881. 


Frozen  Sections  of  a  Child.  9 

are  very  powerful  muscles,  and  their  chief  work  probably  is  to  hold 
the  head  and  neck  firm.  The  trapezii  and  the  sterno-mastoids  are 
both  inclosed  in  the  cervical  fascia,  which  extends  from  the  ligamen- 
tum  nuchae  to  the  median  line,  and  splits  to  receive  them.  From  the 
deep  surface  of  this  fascia,  in  the  anterior  region,  there  pass  off  a 
number  of  layers,  making  sheaths  for  the  smaller  muscles,  joining  the 
capsule  of  the  thyroid  and  the  sheaths  of  the  great  vessels.  The 
sheath  of  the  carotid  must  not  be  considered  as  a  membranous  tube, 
but  rather  as  a  collection  of  dense  areolar  tissue  surrounding  the  ar- 
tery, vein,  and  nerve,  and  running  in  between  them.  The  vein  is 
seen  at  the  outside  of  the  artery,  and  the  nerve  behind ;  on  the  left, 
between  them.  The  small  size  of  the  vein  compared  to  that  of  the 
artery  is  due  to  the  latter  being  injected  and  the  former  empty.  The 
omo-hyoid  lies  at  this  level  on  the  outside  of  the  vessels.  The  pre- 
vertebral  fascia,  binding  down  the  longi  colli,  and  passing  over  the 
scaleni,  is  a  very  distinct  structure.  The  levator  anguli  scapulae  lies 
behind  the  scalenus  medius,  beneath  the  fat  at  the  side  of  the  neck. 
It  slightly  overlaps  the  splenius.  In  rotary  motions  of  the  head  each 
splenius  may  act  with  the  sterno-mastoid  of  the  opposite  side.  It  is 
very  likely,  however,  that  slight  rotary  motions  are  made  chiefly  by 
the  group  of  small  muscles  below  the  occiput. 

The  external  jugular  veins  are  seen  at  the  rear  edge  of  the  ster- 
no-mastoids, outside  of  the  fascia.  The  anterior  jugular  is  normally 
outside  of  the  fascia  :  it  may  be  single  or  double.  It  opens  into  the 
subclavian  vein,  or,  especially  in  the  latter  case,  may  be  connected 
with  both  by  a  transverse  vein  just  above  the  sternum.  The  deep 
plexus  of  veins  in  front  of  the  trachea,  somewhat  below  this  level, 
comes  from  the  thyroid  body,  and  empties  into  the  left  innominate 
vein. 


PLATE  II. 

THIS  plane  is  nearly  level  antero-posteriorly,  though  perhaps  the 
front  is  still  a  little  the  lower,  its  distance  below  the  preceding 
plate  being  about  2  ctm.  We  see  the  lower  part  of  the  first  dorsal 
vertebra,  and,  apparently  behind  it,  owing  to  the  curve  of  the  spine, 
a  part  of  the  intervertebral  disc.  The  arch  and  pedicles  belong 
to  the  second  dorsal.  By  remembering  that  two  ribs  rest,  in 
part  at  least,  against  the  first  dorsal,  we  know  that  till  we  approach 
the  lower  end  of  the  dorsal  region  the  head  of  each  rib  touches 
the  upper  border  of  the  corresponding  dorsal  vertebra.  Thus 
we  see  the  beginning  of  the  second  rib  on  both  sides  at  its  origin, 
and  the  first  rib  cut  obliquely  as  it  descends  to  the  sternum.  The 
relations  may  fairly  be  called  normal,  even  for  the  adult,  as  there  is 
a  great  deal  of  variation  in  the  height  of  the  top  of  the  sternum  and 
in  the  consequent  inclination  of  the  plane  of  the  top  of  the  thorax.  In 
this  case  the  upper  end  of  the  sternum  is  opposite  the  lower  part  of 
the  second  dorsal  vertebra.  This  is,  perhaps,  higher  than  usual. 
The  lungs  are  seen  rising  above  the  clavicles ;  the  left  one  ap- 
pears the  larger,  although  the  section  is  a  little  higher  on  that 
side.  They  reach  to  about  the  level  of  the  head  of  the  first  rib. 
Usually  there  is  little  difference  in  the  height  of  the  apices  which  lie 
far  back  in  the  cage  formed  for  them  by  the  upper  ribs.  The  general 
course  of  the  first  rib  to  the  sternum,  from  the  point  at  which  it  is  di- 
vided, can  easily  be  imagined.  The  pleura  extends  obliquely  forward 
to  the  margin  of  the  rib  beneath  the  structures  which  appear  between 
the  lungs  and  the  clavicles.  The  scaleni  antici1  are  important  land- 
marks. They  reach  the  first  rib  a  little  below  this  section.  The 


1  They  are  not  named  in  the  plate,  but  are  to  be  seen  on  each  side  between  the  two  lines 
that  converge  from  different  parts  of  the  subclavian  artery. 


1 2  Frozen  Sections  of  a  Child. 

phrenic  nerve  is  still  in  front  of  each,  but  gradually  working  its  way 
to  the  inner  side  of  the  muscle.  The  subclavian  vein  is  seen  in  front 
of  the  muscle  on  the  right  side,  but  on  the  left  it  is  just  too  deep.  The 
subclavian  artery  and  the  brachial  plexus  cross  the  first  rib  behind  this 
muscle  and  before  the  scalenus  medius.  According  to  Zuckerkandl 1 
the  artery  and  the  plexus  are  generally  separated  by  the  scalenus 
minimus  (long  known  as  an  anomaly),  which  arises  from  the  trans- 
verse processes  of  the  sixth  and  seventh  cervical  vertebrae,  or  the 
latter  only,  and  from  the  upper  border  of  the  first  rib.  It  runs  to  be 
inserted  into  the  same  rib  between  the  structures  just  mentioned,  but 
it  is  attached  also  to  the  top  of  the  pleura.  Its  chief  purpose  appa- 
rently is  to  strengthen  and  tighten  the  latter.  Sometimes  the  place 
of  the  muscle  is  taken  by  fibrous  bands,  which,  indeed,  had  been  ob- 
served by  Sibson. 

The  cervical  portion  of  the  thymus,  which  often  reaches  to  the 
thyroid,  lies  in  front  of  the  trachea  and  great  vessels.  The  innominate 
divides  just  below  the  surface  of  this  section,  rather  above  the  right 
sterno-clavicular  joint.  The  left  carotid  is  on  the  left  of  the  trachea, 
and  the  left  subclavian  far  back  beside  the  oesophagus.  The  cut  ends 
of  both  subclavian  arteries  show  clearly  how  they  arch  over  the  lung, 
resting  on  the  pleura.  The  internal  mammary  artery  and  vein  lie  in 
the  angle  between  the  right  subclavian  and  the  scalenus  anticus.  On 
the  left,  only  the  artery  is  seen  beside  the  muscle.  The  internal  jug- 
ular appears  on  both  sides,  but  the  subclavian  vein  only  on  the  right. 
The  innominate  veins  begin  just  below  the  section.  The  right  pneu- 
mogastric  nerve  runs  directly  before  the  subclavian  artery,  being  still 
behind  and  between  the  carotid  and  jugular.  The  left  one  is  nearly 
in  front  of  the  carotid.  The  left  recurrent  laryngeal  nerve  runs  in  the 
angle  between  the  trachea  and  oesophagus,  but  the  right  one,  which 
is  given  off  just  in  front  of  the  subclavian,  has  not  yet  had  time  to  get 
there,  and  is  seen  behind  the  artery. 

We  can  now  resume  the  study  of  the  cervical  fascise.  The  an- 
terior layer  splits  below  the  thyroid  into  one  going  to  the  front  of  the 
sternum,  and  into  a  stronger  one  passing  to  its  posterior  surface.  It 
is  seen  separating  the  sterno-hyoids  and  thyroids  from  the  sternal 
insertions  of  the  sterno-mastoids.  This  deeper  layer  gives  off  the 
important  expansion  that  passes  from  the  posterior  belly  of  the  omo- 

1  Zeitschrift  fur  Anatomie-und  Entwickelungsgeschichte,  Band  II. 


Frozen  Sections  of  a  Child.  13 

hyoid  to  the  clavicle  and  the  first  rib.  It  then  invests  the  subclavius 
(which  is  seen  on  the  outer  side  of  both  clavicles),  and  extends  from 
the  first  rib  to  the  coracoid  process.  This  well-defined  fascia  is  called 
the  costo-coracoid  membrane.  It  is  continued  into  the  axilla,  forming 
the  front  portion  of  the  sheath  of  the  axillary  vessels  ;  the  remainder  is 
formed  by  another  prolongation  of  the  deep  cervical  fascia.  The  pre- 
vertebral  fascia  is  very  dense  in  this  region.  Strong  prolongations 
arise  from  it  opposite  the  lower  cervical  and  the  upper  dorsal  verte- 
brse  and  are  attached  to  the  roots  of  the  lungs,  but  more  particularly 
to  the  front  and  back  of  the  pericardium,  and  thus  indirectly  to  the 
diaphragm.  They  may  be  called  its  suspensory  ligaments,  and  pre- 
vent any  serious  sinking  of  its  tendinous  centre.1  The  pericardium  is 
attached  also  to  the  sternum  by  areolar  tissue,  among  which  certain 
bands  may  be  distinguished,  named  by  Luschka  the  superior  and  in- 
ferior sterno-pericardiac  ligaments. 

The  upper  part  of  the  left  shoulder-joint  is  opened,  and  but  a 
small  piece  is  taken  off  from  the  head  of  the  humerus.  The  beginning 
of  the  acromion  is  behind  it,  and  on  the  inner  side  the  upper  surface 
of  the  root  of  the  coracoid  is  seen.  The  superior  angle  of  the  scapula 
is  behind  the  angle  of  the  second  rib,  and  its  posterior  border  ends 
immediately  above  PLATE  V.  Its  relations,  therefore,  are  the  same 
as  in  the  adult :  it  covers  the  ribs  from  the  second  to  the  seventh  in- 
clusive. On  the  right  the  cut  falls  decidedly  lower,  striking  the  glenoid 
cavity,  the  coracoid,  and  the  greater  tuberosity  of  the  humerus.  The 
long  head  of  the  biceps  runs  on  this  side  through  its  sheath  in  the  wall 
of  the  capsule,  but  on  the  left  it  is  seen  inside  the  joint  running  over 
the  head  of  the  humerus.  The  trapezius,  deltoid,  and  pectoralis  major, 
are  all  parts  of  one  muscular  layer.  On  the  left,  the  cephalic  vein  is 
seen  just  after  it  has  pierced  the  fascia  between  the  two  latter.  This 
plate  and  the  next  show  how  liable  the  deltoid  is  to  injury  in  severe 
blows  or  falls  on  the  shoulder.  It  is  quite  as  likely  that  its  very  fre- 
quent wasting  in  such  cases  is  due  to  direct  injury  to  the  muscle  as  to 
the  circumflex  nerve  that  supplies  it.  The  supra-spinatus  is  seen  on 
both  sides,  divided  before  its  insertion.  In  the  specimen,  though  not 
in  the  plate,  fibres  of  the  infra-spinatus  may  be  distinguished  mingling 
with  the  capsule  of  the  right  shoulder.  It  is  worth  while  to  remember 
how  high  up  on  the  greater  tuberosity  these  rotators  are  inserted. 

1  Teutleben  :  Archiv  fur  Anatomic  und  Entwickelungsgeschichte,  1877. 


14  Frozen  Sections  of  a  Child. 

The  serratus  magnus  is  well  shown  beneath  the  scapula,  which 
it  holds  firmly  in  place.  It  is  supplied  by  the  long  thoracic  nerve. 
Its  paralysis  allows  the  posterior  border  of  the  scapula  to  fall  outward 
— "  angel  palsy."  A  somewhat  similar  result  follows  paralysis  of  the 
trapezius,  but  the  eversion  of  the  shoulder  is  less  marked  and  its  fall- 
ing greater.  The  supra-scapular  artery  is  seen  on  the  left,  passing 
over  the  upper  border  of  the  scapula. 


PLATE   III. 

THIS  is  a  little  less  than  2  ctm.  below  the  preceding,  and  very  nearly 
level.  The  reader  is  referred  to  the  plate  for  the  identification 
of  the  vertebrae  and  ribs.  The  cartilage  on  the  side  of  the  sternum 
is  an  expansion  from  that  of  the  first  rib,  which  in  children  may 
reach  nearly  to  the  cartilage  of  the  rib  below  it.  The  manubrium  is 
divided  in  its  lower  half.  The  second  rib,  bone  and  cartilage,  con- 
tinues nearly  horizontally  from  the  point  at  which  it  is  divided  to  its 
insertion.  The  cartilages  of  the  following  ribs,  excepting  the  last 
two,  have  both  a  falling  and  a  rising  portion.  Braune  states  that  at 
about  this  level  the  antero-posterior  diameter  of  the  chest  equals  one- 
third  of  its  breadth,  while  in  the  new-born  child  it  is  one-half.  In  a 
man  of  fifty,  however,  he  found  the  proportion  i  to  2.5,  which  is  very 
nearly  that  of  this  subject.  That,  however,  was  probably  an  indi- 
vidual peculiarity,  and  the  shape  of  the  thorax  at  three,  seems  to  be 
intermediate  between  that  of  the  infant  and  the  adult. 

A  great  deal  more  lung-tissue  is  seen  here  than  in  the  preceding 
plate.  The  pleurae  are  still  far  apart,  not  quite  reaching  the  borders 
of  the  sternum.  Between  them  we  have  the  anterior  mediastinum 
filled  with  areolar  tissue,  bounded  by  the  sternum  in  front  and  the 
aorta  and  vena  cava  behind.  Between  the  latter  and  the  trachea  is 
found  a  large  part  of  the  thymus,  which  is  peculiarly  situated,  as  it  is 
not  common  for  it  to  extend  so  far  back.  It  is  seen  again  in  PLATE 
IV.  in  the  anterior  mediastinum.  This  organ  is  not  rarely  found  in 
the  young  adult.  According  to  Riidinger,  its  involution  does  not  be- 
gin till  the  fifteenth  year.  The  great  fissure  of  the  lungs  begins  on 
the  left,  a  little  above  this  section,  and  on  the  right  just  below  it.  The 
bifurcation  of  the  trachea  is  seen  opposite  the  lower  border  of  the 
fourth  dorsal.  This  is  practically  its  adult  position  in  regard  to  the 
spine,  though  it  is  often  said  to  be  higher.  In  this  child  it  must  be 
rather  below  than  above  the  junction  of  the  first  and  second  pieces  of 
the  sternum.  The  thoracic  duct  lies  on  the  left  of  the  oesophagus  ;  it 
arches  forward  a  little  above  this,  and  was  not  found  in  the  preceding 


1 6  Frozen  Sections  of  a  Child. 

sections.  It  may  rise  as  high  as  the  thyroid  body  before  returning 
to  its  end  at  the  junction  of  the  left  jugular  and  subclavian  veins, 
or  it  may  rise  hardly  at  all  above  that  point.  The  innominate  veins 
are  not  seen,  as  they  run  in  the  thickness  of  the  slice  above  this  plate, 
and  unite  to  form  the  vena  cava  superior  opposite  the  lower  half  of 
the  cartilage  of  the  first  rib,  at  the  right  border  of  the  sternum  behind 
the  thymus.  As  the  cava  descends,  it  inclines  backward,  so  that  in 
PLATE  IV.  it  is  behind  the  aorta,  but,  owing  to  the  spiral  course  of  the 
latter,  it  is  beside  it  again  at  its  termination  just  above  the  level  of 
PLATE  V. 

The  course  of  the  oesophagus  deserves  a  special  description. 
Just  below  its  origin  it  begins  to  incline  to  the  left,  as  is  shown  in  PLATE 
I.  The  deviation  is  more  marked  in  PLATE  II.,  but  in  the  next,  oppo- 
site the  third  and  fourth  dorsal  vertebrae,  it  is  driven  back  toward  the 
middle  by  the  arch  of  the  aorta.  It  continues  for  some  distance  near 
the  median  line.  Opposite  the  ninth  dorsal  it  is  well  to  the  right, 
but  it  then  begins  to  sweep  forward  and  to  the  left.  It  ends  opposite 
the  lower  part  of  the  tenth  dorsal. 

In  another  child,  of  about  the  same  age,  examined  by  means  of 
similar  sections,  the  gullet  at  the  top  of  the  first  dorsal  was  completely 
on  the  left  of  the  trachea,  which  rested  against  the  prevertebral  fascia. 
It  continued  on  the  left,  passing  behind  the  left  bronchus,  till  it  regained 
the  middle  line  opposite  the  seventh  dorsal.  It  then  ran  to  the  left 
again,  in  front  of  the  descending  aorta,  and  ended  at  about  the  upper 
border  of  the  eleventh  dorsal.  In  this  case  there  was  an  effusion  in 
the  right  pleural  cavity.  Braune  states  that  the  greatest  deviation  to 
the  left  is  in  the  region  of  the  second  and  third  dorsals  ;  Tillaux,  that 
the  general  direction  is  to  the  left,  but  that  it  is  slightly  deflected  to 
the  right,  opposite  the  third  dorsal,  by  the  arch  of  the  aorta.  An  ex- 
amination of  sections  by  Pirogoff,  Braune,  Riidinger,  and  Henke, 
shows  that  there  is  great  individual  variation.  Whether  pleuritic  ef- 
fusions can  displace  the  gullet,  is  important,  but  unsettled.  One  point 
seems  reasonably  certain,  that  at  the  bifurcation  of  the  trachea  it 
usually  passes  behind  the  left  bronchus,  and,  as  far  as  I  know,  never 
behind  the  right  one,  excepting  when  all  the  viscera  are  transposed. 
Muscular  fibres  frequently  pass  from  the  left  bronchus  to  the  oesopha- 
gus, and  in  nine  cases  in  which  Gruber  1  found  a  muscle  arising  from 
the  right  bronchus,  in  every  one  its  fibres  ran  from  the  bronchus  di- 

1  Reichert  und  Du  Bois  Reymond's  Archiv.,  1869. 


Frozen  Sections  of  a  Child.  \  7 

rectly  or  obliquely  to  the  left.  Various  other  irregular  muscular  bun- 
dles connect  the  gullet  with  the  pleurae  and  pericardium.  The  aorta 
is  in  close  connection  with  the  oesophagus  for  a  great  part  of  its 
course.  This  we  shall  return  to.  PLATE  V.  shows  the  relations  to 
the  left  auricle  and  right  pulmonary  vein  to  the  oesophagus. 

The  views  of  the  intra-thoracic  nerves  in  Plate  III.  are  very  in- 
structive. The  phrenics  are  seen  far  forward,  especially  the  left  one, 
which  lies  between  the  opposed  surfaces  of  the  pericardium  and 
pleura.  The  right,  which  has  not  yet  reached  a  corresponding  posi- 
tion, lies  behind  the  vena  cava.  The  right  pneumogastric  has  joined 
the  oesophagus  ;  the  left  one,  at  the  left  of  the  arch  of  the  aorta,  gives 
off  the  recurrent  laryngeal,  which  emerges  between  the  aorta  and 
trachea.  The  phrenics  pass  in  front  of  the  roots  of  the  lungs  ;  the 
pneumogastrics  behind  them,  as  is  clearly  shown  in  PLATE  IV.  The 
pericardium  is  seen  covering  the  right  anterior  surface  of  the  ascend- 
ing aorta.  The  course  of  that  vessel  is  left  for  the  next  chapter. 

The  left  scapula  is  cut  just  under  the  glenoid  cavity,  the  right 
one  lower  still.  In  both  cases  the  joint  is  opened  where  the  cap- 
sule hangs  down  in  a  fold,  which  is  obliterated  when  the  arm  is 
raised.  A  small  bursa  is  found  on  each  side  between  the  humerus 
and  the  pectoralis  minor.  The  subscapularis  and  the  infra-spinatus, 
separated  by  the  body  of  the  scapula,  are  easily  known.  The  teres 
minor  lies  against  the  latter  muscle.  On  the  right,  the  long  head  of 
the  triceps,  represented  too  much  like  fibrous  tissue,  runs  along  the 
anterior  border  of  the  scapula.  On  the  left  it  becomes  muscular  at 
once,  and  is  seen  outside  of  the  teres  minor. 

The  axilla  is  shown  as  a  small  space,  containing  the  large  vessels 
and  nerves,  surrounded  by  areolar  and  fatty  tissue.  It  is  bounded  on 
the  inside  by  the  chest- wall,  in  front  by  the  lesser  pectoral,  on  the  out- 
side by  the  coraco-brachialis,  and  behind  by  the  subscapularis.  Its  lower 
wall  is  formed  by  the  skin,  which  is  held  close  up  by  the  axillary  fascia. 
The  axilla  ends  above  by  the  convergence  of  its  walls  (PLATE  II.). 

The  trapezius  is  slightly  shaded  in  this  plate.  Below  are  the 
rhomboids,  running  to  the  posterior  border  of  the  scapula.  It  is  im- 
portant to  know  that  there  is  a  small  space  under  the  scapula,  usually 
containing  a  little  fat,  bounded  by  the  chest-wall,  the  rhomboid,  and 
the  serratus.  Pus  occasionally  is  found  in  it,  and  as  the  serratus  does 
not  allow  the  abscess  to  point  in  the  axilla,  it  may  attain  a  large  size 
and  give  much  pain  before  it  is  recognized. 
3 


^ 


* 


<^ 


. 

**  ~%  *-•*    «  ;...;-,*->••.,  #^/- 


PLATE   IV. 

THIS  is  about  1.8  ctm.  below  the  preceding  surface,  and  slightly 
nearer  to  it  in  front  than  behind.  It  is,  however,  practically 
horizontal,  and  falls  just  below  the  axillae.  The  apex  of  the  spine  of  the 
fifth  dorsal  appears  on  a  level  with  the  lower  part  of  the  body  of  that 
vertebra.  The  second  piece  of  the  sternum  is  divided  just  above  the 
third  cartilage.  The  cartilage  of  the  second  rib  just  touches  this 
plane,  showing  that  in  this  instance,  at  least,  it  describes  a  curve, 
though  a  slight  one. 

This  plate  and  its  two  neighbors  show  admirably  the  relations  of 
the  great  vessels  and  of  the  roots  of  the  lungs.  The  pleurae  nearly 
meet  behind  the  sternum,  where  they  overlap  the  thymus.  -The  peri- 
cardium is  opened  widely  above  the  auricles.  It  is  folded  in  between 
the  aorta  and  the  vena  cava,  follows  the  former  till  it  begins  to  turn 
backward,  and  passes  round  the  front  and  side  of  the  pulmonary 
artery. 

The  pulmonary  artery  and  the  aorta  are  twisted  round  one  an- 
other. The  former  arises  not  quite  in  front  of  the  latter,  as  is  some- 
times taught,  but  a  little  more  to  the  left,  behind  the  left  border  of 
the  sternum  at  the  lower  edge  of  the  third  cartilage.  The  auricular 
appendages  hang  on  either  side  of  it.  One  of  its  valves  is  behind, 
two  in  front.  The  vessel  runs  upward,  backward,  and  slightly  to  the 
left,  dividing  beneath  the  aortic  arch  opposite  the  junction  of  the  car- 
tilage of  the  second  rib  to  the  sternum.  The  right  division  is  seen 
in  this  plate,  the  left  is  higher.  The  aorta  arises  lower,  the  central 
point  of  its  lumen  at  its  origin  being  a  little  above  the  plane  of  PLATE 
V.,  behind  the  sternum,  on  a  level  with  the  upper  border  of  the  fourth 
cartilage.  This  is  a  very  little  lower  than  it  is  usually  placed,  namely, 
opposite  the  third  intercostal  space,  or  even  the  third  cartilages. 
The  aortic  valves  have  been  described  in  various  ways.  There  are 
two  behind  and  one  in  front.  The  right  one  of  the  former  and  the 


20  Frozen  Sections  of  a  Child. 

greater  part  of  the  latter  are  seen  in  PLATE  V.  The  third  is  at  a 
higher  level.  I  have  followed  Sibson's *  nomenclature,  but  it  seems 
as  if  it  would  be  quite  as  well  to  say  that  there  is  a  superior  one  on 
the  left,  and  two  inferior  on  the  right.  One  of  the  sinuses  of  Val- 
salva  corresponds  with  each  flap.  The  superior  sinus  is  the  largest ; 
it  gives  off  the  left  coronary  artery.  The  right  artery  springs  from 
the  anterior  sinus.  The  aorta  runs  forward,  upward,  and  to  the  right. 
In  PLATE  IV.  the  pulmonary  artery  is  on  its  left,  and  the  superior 
cava  almost  behind  it.  At  this  plane  it  changes  its  direction  and  runs 
more  distinctly  forward  and  to  the  left.  In  PLATE  III.  it  is  behind  the 
sternum  at  the  height  of  the  first  intercostal  space.  It  is  seen  in  this 
section  arching  over  the  root  of  the  left  lung,  and  we -may  infer  that 
the  highest  point  of  the  arch  is  opposite  the  top  of  the  third  dorsal 
vertebra  and  below  the  top  of  the  sternum.  Inasmuch  as  these  two 
points  are  in  no  constant  relation  to  each  other,  we  must  consider 
what  is  the  proper  position  of  the  top  of  the  arch  with  regard  to  each. 
Sibson 2  found  the  top  of  the  arch  in  one  instance  one  and  one-half 
inch  below  the  top  of  the  manubrium,  and  in  another  one-half  inch 
above  it.  In  five  cases  he  found  it  above,  and  in  six  on  a  level  with 
the  top  of  the  sternum,  while  in  seven  it  was  quite  an  inch  below  it. 
"  In  two-thirds  of  the  instances  (thirty  in  forty-eight),  however,  the 
top  of  the  aorta  occupied  an  intermediate  place  behind  the  upper  half 
of  the  manubrium,  its  average  position  being  half  an  inch  below  the 
top  of  the  bone."  The  position  of  the  highest  point  of  the  arch  on  a 
level  with  the  upper  part  of  the  third  dorsal  vertebra  is  rather  higher 
than  is  normal  in  the  adult,3  although  good  text-books  place  it  as  high 
as  the  second.  The  rapid  decrease  in  size  of  the  arch  of  the  aorta 
is  partly  real  and  partly  apparent.  It  becomes  smaller  after  giving 
off  the  great  arterial  branches,  and,  moreover,  the  section  strikes  it 
below  its  greatest  diameter.  The  descending  aorta  proper  begins 
between  PLATES  III.  and  IV.,  say  between  the  fourth  and  fifth  dorsals. 
The  close  relation  of  the  aorta  to  the  cesophagus  from  this  point  to 
the  diaphragm  should  be  carefully  noticed.  The  aorta,  which  in 
PLATE  IV.  is  quite  on  the  side  of  the  spinal  column,  gradually  passes 

1  The  Position  and  Form  of  the  Heart  and  Great  Vessels.    Reynolds'  System  of  Med- 
icine.   Vol.  IV. 

2  Loc.  cit. 

3  Mr.  J.  Wood  :  The  Topographical  Relations  of  the  Arch  of  the  Aorta  and  the  Posterior 
Mediastinum  to  the  Spinal  Column.     Journal  of  Anatomy  and  Physiology.    Vol.  III. 


Frozen  Sections  of  a  Child.  2 1 

in  front  of  it,  getting  behind  the  gullet,  as  is  shown  in  PLATES  VI.  and 
VII.  It  runs  through  the  diaphragm  below  PLATE  VIII.,  opposite 
the  twelfth  dorsal  vertebra. 

The  root  of  the  lung  is  composed  of  the  bronchus,  blood-vessels, 
nerves,  and  lymphatics.  The  most  important  of  these  structures  are 
seen  in  PLATE  IV.  The  right  bronchus  is  larger  than  its  fellow, 
which  is  normal,  and  appears  to  descend  more  rapidly,  which  is  not. 
On  the  right,  the  right  branch  of  the  artery  is  in  front  of  the  bronchus, 
and  a  branch  of  the  superior  vein  before  that.  On  the  left  the  vein 
is  in  front  of  the  bronchus,  and  the  artery  behind ;  but  if  the  section 
had  been  made  a  little  higher  the  story  would  have  been  different, 
for  the  left  pulmonary  artery  would  have  been  seen  arching  over  the 
bronchus,  and  but  little  of  the  vein  would  have  been  seen.  PLATE  V. 
shows  the  lower  right  pulmonary  vein  opening  into  the  left  auricle.  The 
left  one  is  cut  while  it  is  rising  toward  the  heart.  In  fact,  each  of  the 
left  pulmonary  veins  opens  into  the  heart  somewhat  above  its  fellow. 
According  to  the  usual  description,  the  order  from  above  downward 
is  as  follows  :  on  the  right,  bronchus,  artery,  veins  ;  on  the  left,  ar- 
tery, bronchus,  veins  ;  and  from  before  backward  on  both  sides,  veins, 
artery,  bronchus.  This  order  from  above  downward  is  in  the  main 
correct,  but  in  the  other  direction  it  can  include  only  the  superior  pul- 
monary veins,  for  PLATE  V.  shows  clearly  that  the  inferior  ones  can- 
not be  in  a  plane  anterior  to  that  of  the  arteries. 

A  mass  of  enlarged  and  degenerated  glands  lies  beneath  the 
bifurcation  of  the  trachea.  This,  together  with  the  bronchi,  forms  at 
this  level  the  front  wall  of  the  posterior  mediastinum.  The  lateral 
walls  are  formed  by  folds  of  the  pleurae.  The  contents  are  the  aorta, 
the  oesophagus,  with  the  pneumogastric  nerves,  the  thoracic  duct,  and 
the  vena  azygos.  It  contains,  also,  sympathetic  nerves,  but  they  were 
not  recognized.  The  vena  azygos  arches  over  the  root  of  the  right 
lung  to  join  the  vena  cava  just  above  the  pericardium.  It  constitutes 
a  very  important  connection  between  the  systems  of  the  upper  and 
lower  venae  cavse. 


PLATE  V. 

THIS  represents  a  pretty  even  section,  1.8  ctm.  below  the  pre- 
ceding one.  Three  vertebrae  are  shown.  The  body  of  the 
seventh  dorsal  is  cut  about  the  middle.  The  arch  belongs  to  the 
same  vertebra,  but  the  articular  processes  of  the  eighth  appear  be- 
fore it ;  and  behind  is  the  tip  of  the  spinous  process  of  the  sixth. 

The  dorsal  region  forms  47.6  per  cent,  of  the  spine  above  the 
sacrum,  and  keeps  very  nearly  the  same  relative  length  in  the  embryo 
and  throughout  life.  Its  mean  length  in  the  adult  is  28.5  ctm.  The 
intervertebral  discs  constitute  a  little  more  than  a  quarter — 26.4  per 
cent. — of  the  dorsal  region.  The  eighth  rib  is  just  below  the  plane  of 
the  section  on  the  left,  and  still  deeper  on  the  right.  The  third  rib 
is  shown  on  the  right  just  where  it  joins  its  cartilage.  The  latter 
rises  very  rapidly  as  it  approaches  the  sternum.  This  bone  is  cut 
where  the  fourth  cartilages  join  it  between  its  third  and  fourth  pieces. 
The  scapulae  end  just  above  this  plane.  The  differences  between  the 
relations  of  the  antero-posterior  and  the  transverse  diameters  of  the 
thorax  of  the  child  and  of  the  adult  are  much  more  marked  at  about 
this  level  than  at  the  highest  part  of  the  cavity.  Thus,  in  this  plate, 
the  former  diameter  is  to  the  latter  about  as  i  to  2,  while  in  the  adult 
it  varies  from  as  i  to  2.5  to  as  i  to  3.  At  birth  it  is  nearly  as  2  to 
3.  The  nipple  is  on  the  front  wall  of  this  slice  opposite  the  fourth 
rib  on  both  sides.  Luschka  found  it  in  the  fourth  intercostal  space 
forty-four  times  out  of  sixty  in  males.  In  women  it  is  said  to  be  op- 
posite the  fifth  rib  ;  but,  owing  to  the  great  variety  of  forms  and  sizes 
of  the  breast,  it  is  of  no  constant  value  as  a  landmark  in  women. 

This  cut  is  a  remarkably  fortunate  one,  for  it  has  struck  the  heart 
so  as  to  open  its  four  cavities,  and  to  show  both  the  valves  of  the  left 
ventricle.  Three-fourths  of  the  heart,  as  seen  in  this  plate,  belong 


24  Frozen  Sections  of  a  CJiild. 

to  the  left  side,  and  both  this  view  and  the  next  show  how  this  ap- 
pears to  be  the  important  side  of  the  heart,  and  the  right  merely  an 
addition  to  it ;  yet  before  birth  the  two  sides  are  of  about  equal 
strength.  The  conus  arteriosus,  a  prolongation  upward  of  the  right 
ventricle  to  the  pulmonary  artery,  is  nearly  in  front  of  the  aortic 
valves,  two  of  which  appear  in  this  plate.  Behind  them  is  the  mitral 
valve,  consisting  of  two  segments — an  anterior  one  on  the  right,  a 
posterior  one  on  the  left.  The  valve  is  closed ;  it  lies  behind  the  left 
border  of  the  sternum,  and  at  this  level  is  opposite  the  fourth  cartil- 
age. There  was  some  difficulty  in  defining  its  limits  quite  accurately, 
but  they  seem  to  correspond  very  well  with  the  normal  ones  of  the 
adult,  namely,  from  the  third  space  to  the  fifth  cartilage.  The  pul- 
monary valves  are  higher  than  the  aortic,  which  are  higher  than  the 
mitral,  and  the  tricuspid  is  the  lowest.  No  one  of  these  valves,  how- 
ever, is  completely  above  the  one  next  below  it — they  all  overlap. 
The  left  auricle  appears  in  this  plate  to  deserve  to  be  called  the  pos- 
terior one,  but  PLATE  IV.  shows  it  extending  forward  on  the  left. 

The  pleural  cavities  are  about  as  near  together  behind  the 
sternum  as  in  the  preceding  plate,  but  the  left  lung  makes  way  for 
the  heart.  Usually,  a  needle  thrust  through  the  fifth  or  sixth  inter- 
costal space,  and  sometimes  through  the  fourth  at  the  left  border  of 
the  sternum,  will  pierce  the  pericardium  and  not  the  pleura.  The 
great  fissure  of  the  left  lung  begins  rather  above  the  head  of  the 
fourth  rib,  that  of  the  right  rather  below  it.  The  third,  or  middle, 
lobe  of  the  right  lung  is  shown  in  PLATE  V.  It  varies  in  size  and 
shape,  according  as  the  fissure  that  forms  its  upper  boundary  runs 
upward  from  the  main  fissure  from  which  it  springs,  directly  forward, 
or  downward,  as  in  this  case.  As  a  rule,  the  main  fissure  usually 
strikes  the  lower  surface  of  the  lung,  so  that  the  front  of  the  lung  is 
formed  entirely  by  the  upper  lobe,  or  by  the  upper  and  middle  lobe 
on  the  right.1  In  this  case  the  middle  lobe  is  a  tongue-shaped  body 
of  little  consequence,  and  the  upper  lobes  form  but  a  very  small  part 
of  the  base  of  both  lungs. 

An  extra  lobe  of  the  right  lung  may  be  formed  by  the  abnormal 
course  of  the  vena  azygos,  which  makes  a  groove  in  the  top  of  the 


1  Dr.  Cilley,  of  Cincinnati,  has  the  credit,  I  believe,  of  being  the  first  to  call  attention  to 
this  in  any  publication  in  English.  Vide  Cincinnati  Lancet  and  Clinic,  1881.  The  fact  was, 
however,  already  known  to  German  anatomists. 


Frozen  Sections  of  a  Child.  25 

lung  as  it  runs  to  open  into  the  superior  cava  near  its  beginning  in- 
stead of  near  its  end.1  Chiene  describes  a  case  in  which  the  vena 
azygos  left  the  spine  at  the  fifth  dorsal  vertebrae,  and,  running  in  the 
edge  of  a  fold  of  pleura,  cut  out  an  extra  pear-shaped  lobe  in  the  right 
lung,  which  had  its  origin  in  the  angle  formed  by  the  junction  of  the 
upper  lobe  with  the  root  of  the  lung.2 


1  Gruber  :  Bulletin  de  I'Academie  de  St.  Petersburg.     Vol.  XV.     1871. 
'2  Journal  of  Anatomy  and  Physiology.     Vol.  IV. 

4 


PLATE   VI. 

THIS  is  1.8  ctm.  below  the  preceding.  The  cut  runs,  perhaps,  a 
little  obliquely,  so  as  to  strike  the  front  wall  of  the  chest  a  little 
higher  than  it  should.  There,  however,  is  no  serious  error  in  assum- 
ing that  the  section  is  a  true  one.  We  are  struck  at  once  with  a 
peculiarity  depending  on  the  age  of  the  subject.  The  disc  between 
the  eighth  and  ninth  dorsal  vertebrae  appears  on  a  level  with  the  be- 
ginning of  the  ensiform  cartilage,  which  is  seen  just  behind  the  carti- 
lages of  the  seventh  ribs,  which  are  about  to  meet.  In  the  adult  of 
either  sex  the  sternal  end  of  the  seventh  pair  of  ribs  would  be  found 
opposite  a  lower  point.  Luschka  places  them  opposite  the  vertebral 
end  of  the  eleventh  pair.  A  horizontal  section  by  Braune,  through  the 
upper  part  of  the  ninth  dorsal  vertebrae,  strikes  the  sternum  at  the 
sixth  intercostal  space.  A  comparison  with  other  sections  leads  to 
the  belief  that  the  latter  is  a  more  usual  relation  than  Luschka's. 
The  relations  of  the  sternum  in  this  child  correspond  remarkably  with 
those  of  the  adult  till  we  reach  the  lower  part  of  the  body  of  the  ster- 
num, which  is  smaller  than  it  should  be,  so  that  the  fifth,  sixth,  and 
seventh  ribs  are  crowded  together  at  their  sternal  ends. 

The  sternum  varies  extremely  in  length  and  in  the  relative  size 
of  its  parts.  Tillaux  states  that  it  increases  with  the  height  of  the 
body,  but  that  many  exceptions  occur — both  of  which  statements  agree 
with  my  observations.  Hyrtl  states  very  certainly  that  "the  manu- 
brium  of  the  female  sternum  exceeds  half  the  length  of  the  body,  while 
the  body  of  the  male  sternum  is  at  least  twice  as  long  as  the  manu- 
brium."  I  found  that  this  did  not  apply  to  the  breastbones  of  twelve 
men  out  of  thirty,  nor  to  those  of  fourteen  out  of  twenty-six  women. 
The  male  sternum  is  usually  decidedly  larger  than  the  female.  The 
above-mentioned  measurements  give  a  mean  of  5.18  ctm.  for  the  male 
manubrium,  and  of  4.67  ctm.  for  the  female  ;  of  10.59  ctm.  for  the  body 


28  Frozen  Sections  of  a  Child. 

of  the  male  sternum,  and  of  8.94  ctm.  for  the  female.1  The  history  of 
the  development  of  the  sternum  has  not  been  thoroughly  studied.  I 
believe  that  the  lower  part  of  the  body  of  the  bone  is  proportionally 
small  in  early  childhood,  which  occasions  discrepancies  with  the  rela- 
tions of  the  adult,  as  occurs  in  this  subject. 

The  upper  surface  of  the  diaphragm,  separating  the  right  lung 
from  the  liver,  is  just  grazed  in  this  section.  The  view  of  the  heart 
shows  the  right  auricle  resting  on  the  liver,  the  right  ventricle,  and 
the  lower  posterior  wall  of  the  left  one.  The  apex  is  seen  in  PLATE 
VII.  In  the  section  before  us,  the  lower  segment  of  the  tricuspid  is 
seen  lying  on  the  lower  wall.  The  other  two  are  placed  higher,  one 
attached  to  the  front  wall,  the  other  to  the  septum.  It  is  not  easy  to 
define  accurately  the  position  of  the  valve,  but  we  may  say  that  it  lies 
behind  the  lower  fourth  of  the  sternum,  and  that  its  upper  border 
probably  does  not  quite  reach  the  level  of  the  fourth  cartilage,  as  it 
should.  The  floor  of  the  right  auricle  presents  nothing  of  interest, 
excepting  the  remains  of  the  Eustachian  valve,  the  edge  of  which  ap- 
pears as  a  line  in  front  of  the  orifice  of  the  vena  cava  inferior.  It  is 
easy  to  see,  by  looking  at  PLATE  V.,  how  this  valve,  when  more  de- 
veloped, as  in  intra-uterine  life,  would  direct  the  current  toward  the 
fenestra  ova.lis,  which  must  have  been  in  the  oblique  inter-auricular 
septum,  the  top  of  which  is  seen  in  that  plate.  The  vena  cava  inferior 
passes  through  the  tendinous  part  of  the  diaphragm  opposite  the 
lower  part  of  the  body  of  the  ninth  dorsal  vertebra.  It  is  kept  widely 
distended  by  its  firm  attachments  to  the  diaphragm.  Thus,  even  at 
this  age  this  vein  exists  as  a  distinct  vessel  above  the  diaphragm.  At 
birth  it  opens  into  the  heart  almost  immediately  after  passing  the 
foramen.  In  the  adult  the  vessel  runs  upward  and  bends  toward  the 
left.  As  the  foramen  through  the  diaphragm  is  about  horizontal,  and 
the  opening  into  the  heart  nearly  vertical,  it  follows  that  the  posterior 
and  right  surface  of  the  vein  is  longer  than  its  anterior  and  left  one. 
According  to  Luschka,  the  former  is  3.8  ctm.,  the  latter  2. 2  ctm.  The 
vein  contains  no  muscular  fibres  above  the  diaphragm,  but  fibres  from 
the  heart  end  tendinously  in  its  walls,  apparently  to  expand,  not  to 
constrict  it.  It  is  covered  by  the  pericardium  in  its  upper  two-thirds. 

We  will  now  endeavor  to  define  the  position  of  the  heart.  The 
apex  is  on  a  level  with  the  upper  border  of  the  cartilage  of  the  sixth 

1  Journal  of  Anatomy  and  Physiology.     Vol.  XV.     1881. 


Frozen  Sections  of  a  Child.  29 

rib  at  its  most  dependent  part,  3.2  ctm.  below  the  nipple,  and  at  least 
i  ctm.  inside  of  it.  The  lower  end  of  the  auriculo-ventricular  groove 
is  at  the  right  of  the  base  of  the  ensiform  cartilage,  opposite  the  car- 
tilage of  the  sixth  rib  as  it  rises  to  join  the  sternum,  and  about  i  ctm. 
to  the  right  of  the  median  line.  The  lower  border  of  the  heart  would 
be  represented  by  a  slightly  curved  line  connecting  these  points.  The 
auriculo-ventricular  groove  runs  upward  to  the  middle  of  the  line  be- 
tween the  cartilages  of  the  third  ribs.  The  right  auricular  appendage 
is  seen  rather  above  that  level  in  PLATE  IV.,  and  in  the  same  plate  the 
left  auricle,  which  constitutes,  perhaps,  the  highest  point  of  the  heart, 
is  opposite  the  lowest  part  of  the  second  intercostal  space  at  the  side 
of  the  sternum.  The  position  of  the  heart  is,  therefore,  practically 
normal,  even  for  the  adult.  The  apex1  is  rather  lower  than  usual  in 
relation  to  the  ribs,  but  possibly  this  would  have  been  corrected  as 
the  lower  part  of  the  sternum  became  more  developed.  The  greatest 
breadth  of  the  heart  is  seen  in  PLATE  VI.,  and  more  of  the  heart  lies 
in  contact  with  the  chest  than  at  the  level  of  any  other  plate. 

The  pericardium  rests  upon  the  central  tendon  of  the  diaphragm, 
but  it  extends  over  on  to  the  muscular  part  both  to  the  right  and  the 
left.  The  attachment  of  the  front  wall  of  the  pericardium  to  the  dia- 
phragm is  particularly  firm. 

This  plate  shows  a  change  in  the  shape  of  the  posterior  medias- 
tinum, which  is  caused  by  the  aorta  having  made  its  way  to  the  front 
of  the  column,  crowding  the  oesophagus  and  the  vena  azygos  to  the 
right. 

1  "  The  lower  edge  of  the  apex  was  on  a  level  with  the  lower  edge  of  the  left  fifth  carti- 
lage in  one-seventh  of  the  instances  observed  (six  in  sixty-nine)  ;  it  was  below  that  edge  in 
two-fifths  of  them  (twenty-six  in  sixty-nine)  ;  and  it  was  above  that  edge  in  almost  one-half 
of  them  (thirty-four  in  sixty-nine).  In  five  instances  the  lower  boundary  of  the  apex  was 
situated  one  inch  above  the  lower  edge  of  the  fifth  cartilage,  and  in  four  it  was  fully  one  inch 
below  that  edge." — Sibson  :  loc.  cit. 


-T- 


PLATE    VII. 

AN  even  section  about  1.6  ctm.  below  the  last.  It  shows  impor- 
tant relations  in  both  the  thoracic  and  abdominal  regions.  The 
diaphragm  is  seen  separating  the  cavities,  except  in  front,  where  it 
passes  for  a  short  space  above  this  section.  The  oesophagus,  now  in 
front  of  the  aorta,  opens  just  below  the  level  of  this  section,  opposite 
the  lower  half  of  the  tenth  dorsal.  In  the  adult  its  termination  is 
placed  from  the  ninth  to  the  eleventh.  The  apex  of  the  heart  is  di- 
vided just  at  the  lowest  point  of  the  cavity  of  the  left  ventricle.  Only 
a  very  small  pericardial  cavity  is  seen  around  it.  The  lower  edge  of 
the  right  lung  is  seen  behind  the  liver,  and  that  of  the  left  behind 
the  spleen.  A  very  small  piece  of  the  left  lung  appears  also,  outside 
of  the  apex  of  the  heart,  under  cover  of  the  sixth  rib.  The  posterior 
borders  of  the  lungs  extend  about  6  mm.  below  this  plane.  They 
are,  therefore,  below  the  tenth  rib  at  its  angle.  In  the  mammillary 
and  axillary  lines  they  end  very  near  the  level  of  PLATE  VII.  The 
lungs  are,  of  course,  in  a  state  of  complete  expiration,  and  smaller 
than  they  probably  can  be  during  life,  but  one  of  the  merits  of  a  fro- 
zen section  is  that  it  shows  them  in  much  more  normal  relations  than 
they  would  present  if  the  chest  were  opened  in  the  usual  way,  which 
would  occasion  their  collapse.  The  pleural  cavities  extend  consider- 
ably lower.  They  do  not,  however,  follow  the  diaphragm  into  the 
angle  which  it  forms  with  the  cartilages  of  the  six  lower  ribs ;  the 
very  lowest  part  of  this  space  is  filled  with  areolar  tissue.  The 
pleura  is  described  as  reaching  in  the  mammillary  line  to  the  cartilage 
of  the  sixth,  sometimes  of  the  seventh  rib  ;  and  in  the  axillary  line, 
to  the  lower  border  of  the  ninth  rib  on  the  right,  and  of  the  tenth  on 
the  left.  It  does  not  touch  the  cartilages  of  the  four  or  five  lower  ribs. 
Let  us  compare  this  general  description  with  this  individual,  case. 
In  PLATE  VIII.  the  front  of  the  pleural  cavity  reaches  about  to  the 
mammillary  line.  On  the  left,  it  lies  against  the  seventh  cartilage 


32  Frozen  Sections  of  a  Child. 

near  its  lowest  point.  On  the  right  it  lies  against  the  bony  part  of 
the  same  rib.  (The  right  of  this  section  is  higher  than  the  left.)  In 
PLATE  IX.  it  reaches  the  tenth  rib  on  both  sides,  at  a  point  not  far 
from  the  axillary  line.  It  lies  behind  both  kidneys,  but  covers  more 
of  the  right  one.  On  both  sides,  the  pleura  reaches  the  upper  border 
of  the  last  rib,  near  its  beginning,  but  the  rib  very  soon  runs  away 
from  it,  as  may  be  inferred  from  PLATE  IX.  A  case  has  been  re- 
ported in  which  a  surgeon  operating  in  the  lumbar  region  to  reach 
the  kidney,  mistook  the  eleventh  rib  for  the  twelfth,  and  by  carrying 
the  incision  toward  its  lower  border,  opened  the  pleura.  PLATE  IX. 
shows  that  at  that  level  such  an  incision  opposite  the  kidney  would 
certainly  open  the  pleura  on  the  right,  and  perhaps  on  the  left.  The 
length  of  the  twelfth  rib  is  important  in  this  connection,  for  the  rib 
is  by  no  means  always  easy  to  recognize.  Dr.  Holl 1  examined  sixty 
skeletons  of  all  ages  to  ascertain  the  absolute  and  relative  length  of 
the  twelfth  rib.  As  there  are  two  sides  to  each  subject,  and  the  ribs 
are  not  necessarily  symmetrical,  this  gives  one  hundred  and  twenty 
observations.  The  longest  twelfth  rib  measured  16.0  ctm.  (giants  and 
children  being  omitted),  and  the  shortest,  2.0  ctm.  The  twelfth  was 
three-fourths  of  the  length  of  the  eleventh  in  thirty-three  cases  ;  one- 
half  in  forty-four ;  one-third  in  eighteen  ;  one-fourth  in  fifteen  ;  one- 
sixth  in  three,  and  one-eighth  in  one.  This  shows  how  very  variable 
it  may  be.  Holl  points  out  as  a  fact  of  great  surgical  importance  that 
the  pleura  descends  just  as  far  as  usual  when  the  twelfth  rib  is  want- 
ing, or  but  slightly  developed. 

The  pleura  is  attached  rather  loosely  to  the  walls  of  the  chest  by 
a  layer  of  areolar  tissue,  which  accounts  for  the  slightness  of  the  in- 
jury it  usually  suffers  in  fractures  of  the  ribs. 

For  all  practical  purposes,  we  may  consider  the  diaphragm  as  a 
circular  muscle  whose  fibres  converge  to  the  central  tendon.  This, 
as  stated  above,  is  firmly  attached  to  the  pericardium,  and  through 
this,  to  the  vertebral  column  at  the  top  of  the  thorax,  and  less  firmly 
to  the  cervical  fascia  and  to  the  sternum.  The  bearing  of  these  points 
on  the  mechanism  of  respiration  deserves  careful  study.  The  tho- 
racic cavity  can  be  enlarged  by  the  raising  of  the  upper  ribs  and  of 
the  sternum,  which  together  with  some  slight  rotation  of  the  ribs,  in- 


1  Die  Bedeutung  der  Zwolften  Rippe  bei  der  Nephrotomie.     Archiv  fur  klinische  Chi- 
rurgie.  Band  xxv.,  1880. 


Frozen  Sections  of  a  Child.  33 

creases  both  the  vertical  and  the  transverse  diameters.  An  important 
part  of  the  process,  however,  is  the  contraction  of  the  diaphragm,  by 
which  the  tendinous  centre  is  made  tense,  and  the  abdominal  viscera 
depressed.  Now,  for  the  muscle  to  act  effectively,  its  lateral  points  of 
origin  must  be  fixed,  and  this  is  done  by  the  muscles  that  pull  the 
lower  ribs  downward  and  backward.  Such  are  the  quadratus  lum- 
borum,  the  serratus  posticus  inferior,  and  many  of  the  small  lateral 
bellies  of  the  great  erector  spins.  The  ribs,  therefore,  may  be  pulled 
both  upward  and  downward  in  vigorous  inspiration,  or  at  least  the 
lower  ones  may  be  drawn  rather  backward  and  held  fast.  This 
question  has  been  confused  by  those  who  use  the  words  "  inspiratory  " 
as  applied  to  a  muscle  as  synonymous  with  "raising  the  ribs,"  which 
involves,  if  the  above  view  be  correct,  a  serious  error.  Mechanical 
toys,  like  Hamberger's  bars  are  quite  misleading.  The  vexed  and 
very  complicated  question  of  the  action  of  the  intercostals  is  much 
simplified  by  this  theory.  If  the  movements  of  all  the  ribs  are  not  free 
and  in  the  same  direction,  these  muscles  cannot  have  a  common  ef- 
fect on  all  parts  of  the  thorax.  This  is  true  whether  applied  to  both 
the  external  and  internal  intercostals,  or  to  either  set  separately.  In 
point  of  fact  the  action  of  both  is  simply  to  draw  the  more  movable 
ribs  toward  the  more  fixed.  Those  in  the  upper  part  of  the  chest 
pull  upward,  those  in  the  lower  downward,  and  the  action  of  almost 
any  set  of  them  must  vary  with  circumstances.  There  is,  however, 
another  point  to  be  considered,  namely,  the  effect  of  the  inspiratory 
movement  on  the  great  veins  that  lead  to  the  heart.1  The  opening  of 
the  cava  inferior  through  the  tendinous  portion  is  made  as  large  as 
possible  by  the  contraction  of  that  muscle,  and  the  suction  power,  both 
of  the  inspiratory  enlargement  of  the  chest  and  of  the  relaxing  auricle, 
act  very  strongly  on  the  contents  of  the  vena  cava  and  on  the  portal 
circulation.  Two  large  branches  of  the  hepatic  vein  are  seen  in  PLATE 
VII.  on  their  way  to  the  cava,  which  they  enter  just  below  the  dia- 
phragm. A  similar  effect  is,  no  doubt,  produced  on  the  great  veins  at 
the  root  of  the  neck. 

Leaving  the  liver  and  stomach  for  the  next  chapter,  we  will  dis- 
cuss the  spleen.  It  reaches  nearly,  if  not  quite  as  high,  as  the  stom- 
ach, that  is,  somewhat  below  the  level  of  the  head  of  the  ninth  rib. 
It  extends  to  the  lower  half  of  the  first  lumbar.  It  is  evident  that  the 

1  Forbes  on  the  Diaphragm.     The  American  Journal  of  Medical  Science,  July,  1880. 

5 


34  Frozen  Sections  of  a  Child. 

upper  part  is  nearer  the  spine  than  the  lower.  It  is  entirely  under 
cover  of  the  ribs.  Luschka  describes  it  as  following  the  ninth,  tenth, 
and  eleventh  ribs,  a  description  that  would  apply  very  tolerably  to 
this  case.  The  great  peculiarity  of  the  spleen  in  this  instance  is  its 
relation  to  the  peritoneum.  Usually  it  is  entirely  covered,  except 
near  the  hylus,  with  a  prolongation  from  the  lining  of  the  great  peri- 
toneal cavity,  though  it  is  stated  that  at  least  in  the  young  subject  a 
portion  of  the  lower  and  posterior  surface  derives  its  covering  from 
the  lesser  cavity.  Here,  however,  a  large  part  of  the  organ  is  with- 
out any  serous  covering.  The  anterior  layer  of  the  gastro-splenic 
omentum  may  be  seen  in  PLATE  VIII.,  running  backward  from  the 
outer  surface  of  the  stomach  to  the  inner  one  of  the  spleen,  but  the 
posterior  layer  does  not  exist,  because  the  fold  of  peritoneum,  which 
ought  to  be  carried  around  the  back  of  the  spleen  to  form  it,  is  seen 
stopping  short  between  that  organ  and  the  kidney. 


•fy 


^ 


PLATE  VIII. 

THIS  section,  on  an  average  2  ctm.  below  the  last,  is  unfortunately >• 
uneven  from  side  to  side.  The  left  side  is  perhaps  as  much  as 
5  mm.  below  the  right.  The  column  is  divided  at  the  disc  below  the 
eleventh  dorsal.  The  ribs  are  not  very  unsymmetrical,  but  the  carti- 
lage of  the  seventh  is  divided  at  its  lowest  part  on  the  left,  while  on 
the  right  it  passes  below  the  section.  We  do  not  see  the  head  of  a 
rib  opposite  the  intervertebral  cartilage,  as  the  eleventh  and  twelfth 
ribs  arise  from  their  respective  vertebrae.  The  tenth  usually  arises 
from  the  tenth  vertebra  and  a  part  of  the  cartilage  above  it,  without 
reaching  the  ninth. 

The  liver  fills  a  much  larger  part  of  the  abdomen  than  in  the 
adult,  though  proportionally  smaller  than  in  the  fcetus.  The  greatest 
transverse  diameter  is  shown  in  PLATE  VII.,  but  that  is  not  so  great 
as  is  sometimes  considered  normal  for  the  adult.  The  great  increase 
of  size  is  due  to  the  depth.  It  almost  reaches  the  level  of  PLATE  VI., 
from  which  it  is  separated  only  by  the  diaphragm,  and  it  extends 
downward  below  PLATE  X.  to  the  third  lumbar  vertebra.  The  out- 
line of  the  anterior  edge  can  be  readily  deduced  from  the  plates.  It 
rises  gradually  to  PLATE  IX.,  and  then  more  rapidly.  The  liver  of  a 
healthy  adult  lying  on  his  back  should  not  descend  below  the  border 
of  the  ribs,  except  in  the  region  of  the  ensiform  cartilage.  It  is  evi- 
dent that  in  this  case  the  liver  considerably  exceeds  these  limits. 
This  is  not  the  result  of  disease,  but  a  characteristic  of  the  age  of 
the  child. 

The  liver  is  usually  described  as  having  an  upper  and  a  lower 
surface,  an  anterior  border,  which  is  thin,  and  a  posterior  one,  which 
is  thick,  especially  on  the  right.  The  lobe  of  Spigelius  is  marked  off 
on  the  under  surface  by  the  fissure  of  the  vena  cava  on  the  right,  the 
transverse  one  in  front,  and  that  of  the  obliterated  ductus  venosus  on 
the  left.  How  the  inferior  cava  comes  to  be  lying  along  the  under  sur- 


36  Frozen  Sections  of  a  Child. 

face  is  not  explained.  His1  has  the  merit  of  showing  that  this  descrip- 
tion applies  to  the  liver  removed  from  the  body,  drained  of  its  blood, 
and  distorted  by  its  own  weight.  When  in  situ  the  liver  has  not  a 
posterior  border,  but  a  posterior  surface.  The  vena  cava  makes  a  deep 
groove  in  the  rear,  as  is  seen  in  PLATES  VII.  and  VIII. ;  indeed,  in 
the  former  it  is  almost  surrounded  by  the  liver.  The  lobe  of  Spigelius 
lies  to  the  left  of  it,  and  is,  at  least,  as  much  on  the  hind  as  on  the 
lower  surface  of  the  liver.  The  transverse  fissure,  which  forms  its  an- 
terior boundary,  cuts  through  to  the  level  of  PLATE  VIII.,  and  shows 
the  outline  of  this  lobe  very  clearly.  The  oesophagus  often  makes  a 
slight  groove  in  the  liver.  To  the  left  of  this  the  posterior  surface 
passes  into  the  posterior  border.  The  impression  from  the  right  kid- 
ney is  also  in  part  on  the  posterior  surface,  as  is  shown  in  PLATE  IX. 
The  tissue  of  the  liver  is  very  yielding ;  it  resembles  a  sponge  filled 
with  blood,  and  very  probably  can  undergo  slight  temporary  changes 
of  form  by  the  pressure  of  neighboring  parts.  That  long-continued 
pressure  will  make  permanent  changes  is  well  known.  Hence  it  is 
very  likely  that  the  liver,  which  in  early  fcetal  life  filled  a  great  part  of 
the  abdomen,  is  reduced  to  its  proper  shape  and  size  by  the  pressure 
of  the  growing  organs  around  it.  The  right  coronary  ligament  is 
opposite  the  tenth  rib.  To  understand  its  formation,  remember  that 
a  part  of  the  back  of  the  liver  has  no  peritoneal  covering.  The  serous 
membrane  of  the  top  of  the  liver  is  reflected  upward  and  forward 
under  the  diaphragm  ;  that  of  the  lower  surface  of  the  right  lobe  down- 
ward over  the  posterior  wall.  These  two  folds  approach  one  another 
at  the  right  side  of  the  liver,  and  at  last  meet  back  to  back,  form- 
ing the  triangular  ligament.  The  falciform  ligament  is  seen  in  front, 
running  very  obliquely  to  reach  the  umbilical  fissure  which  appears  in 
PLATE  IX.  The  aorta  is  about  passing  through  the  diaphragm  at  this 
level.  Immediately  after  this  it  gives  off  the  cceliac  axis,  of  which  all 
three  branches  are  seen  in  this  plate.  The  splenic  is  seen  near  the 
front  surface  of  the  spleen,  the  coronary  of  the  stomach  between  that 
organ  and  the  liver,  and  the  hepatic  in  the  transverse  fissure.  A 
branch  of  the  portal  vein  lies  in  the  right  division  of  this  fissure. 
Both  the  supra-renal  capsules  are  shown,  presenting,  however,  quite 
different  outlines.  In  front  of  .the  left  one  lies  a  ganglion  of  the  sym- 
pathetic system. 


1  Archiv  fur  Anatomic  und  Entwickelungsgeschichte.     1878. 


Frozen  Sections  of  a  Child.  37 

The  views  of  the  stomach  are  very  instructive.  They  confirm 
entirely  Luschka's  statement  that  the  fundus  points  upward,  and  that 
the  lesser  curvature  is  essentially  vertical.  It  is  astonishing  to  find  it 
still  described  as  the  upper  border  of  the  stomach.  The  fundus 
reaches  nearly  as  high  as  the  liver.  In  the  axillary  line  it  is  opposite 
the  seventh  rib.  In  PLATE  VII.  it  is  seen  cut  transversely.  The  next 
view  shows  the  stomach  changing  its  position,  running  at  first  forward, 
and  then  turning  to  the  right  beneath  the  liver.  The  lowest  part  of 
the  greater  curvature  is  seen  in  PLATE  X.  This  shows  also  precisely 
how  far  it  extends  to  the  right.  Certainly  five-sixths  of  the  stomach 
are  on  the  left  of  the  median  line,  as  Luschka  states.  The  pylorus  is 
seen  in  PLATE  IX.,  opposite  the  first  lumbar  vertebra.  By  comparing 
this  plate  with  the  two  preceding,  the  direction  of  the  lesser  curvature 
can  be  made  out.  The  pylorus  is  usually  found  between  the  ensiform 
cartilage  and  the  right  costal  arch.1 

Some  important  relations  of  the  peritoneum  can  be  studied  in 
PLATE  VIII.  The  space  behind  the  stomach,  which  extends  down 
into  the  great  omentum,  is  a  part  of  the  lesser  peritoneal  cavity  and 
communicates  with  the  general  cavity  by  the  foramen  of  Winslow. 
Remembering  that  this  foramen  is  bounded  below  by  the  duodenum, 
in  front  by  the  portal  vessels,  behind  by  the  vena  cava,  and  above  by 
the  lobe  of  Spigelius,  we  see  that  a  line  drawn  directly  forward  in  this 
section,  from  the  vena  cava  to  the  transverse  fissure,  would  indicate 
its  position,  and,  indeed,  be  separated  from  it  only  by  a  thin  layer  of 
liver.  The  •<  shaped  peritoneal  cavity,  which  we  see  to  the  left  of 
the  lobe  of  Spigelius,  also  belongs  to  the  cavity  of  the  omentum. 
Its  anterior  wall  in  this  place  is  formed  by  the  gastro-hepatic  omen- 
turn,  a  double  layer  of  peritoneum  running  from  the  transverse  fis- 
sure to  the  lesser  curvature.  A  considerable  part  of  the  spleen  is 
shown  at  this  level  without  peritoneal  covering. 


1  If  I  remember  rightly,  the  stomach  contained  frozen  milk  when  the  section  was  made. 
It  was  very  moderately  distended.  The  fact  that  the  lowest  part  of  the  stomach  is  contracted 
and  the  upper  dilated  is  easily  understood  when  it  is  remembered  that  the  body  was  frozen  lying 
on  its  back  ;  so  that  the  contents  of  the  stomach  would  naturally  gravitate  toward  the  fundus. 


v^ 


PLATE    IX. 

THIS  section  is,  perhaps,  on  the  average,  1.8  ctm.  below  the  pre- 
ceding, and  is  practically  level.  The  cancellated  tissue  of  the 
first  lumbar  vertebra  is  just  nicked  at  its  highest  point.  The  rela- 
tions correspond  remarkably  well  with  those  shown  in  one  of  Braune's 
sections  through  the  middle  of  the  same  vertebra,  the  chief  difference 
being  that  this  plate  shows  more  of  the  liver  and  stomach.  The  last 
four  ribs  are  shown  on  both  sides,  and  each  ninth  rib  is  cut  at  its 
junction  with  its  cartilage.  In  Braune's  plate  the  lowest  part  of  the 
seventh  is  shown  on  one  side  pretty  much  as  it  is  shown  in  PLATE 
VIII.  From  this  we  may  infer  that  not  only  are  the  stomach  and 
liver  proportionally  larger  in  the  child,  but  also  that  the  lower  part 
of  the  front  of  the  thorax  does  not  descend  so  low  as  in  the  adult. 
The  lowest  part  of  the  pleura  is  seen  on  each  side.  The  umbilical 
fissure,  containing  the  falciform  ligament,  cuts  off  the  left  lobe  of  the 
liver.  The  gall-bladder  is  opened.  It  does  not  extend  so  far  forward 
as  in  the  adult.  The  kidneys  lie  on  each  side  of  the  spinal  column. 
The  left  one  is  divided  near  its  middle,  the  right  one  above  it.  The 
aorta,  lying  between  the  vertebral  origins  of  the  diaphragm,  is  seen 
giving  off  the  superior  mesenteric  artery.  The  portal  vein  is  directly 
before  it,  below  the  pancreas.  This  is  formed  by  the  junction  of  the 
splenic  and  superior  mesenteric  veins.  The  inferior  mesenteric  is  a 
tributary  of  the  former.  The  vena  cava  appears  immense  in  this  sec- 
tion, which  is  due  to  the  fact  that  the  right  renal  vein  is  laid  open  at 
its  entrance  into  it,  so  that  they  are  shown  as  one.  Valves  at  or  near 
the  mouth  of  each  renal  vein  and  those  of  the  spermatic  veins  have 
been  alluded  to,  but  the  slight  descriptions  given  of  them  do  not 
agree.  Mr.  Rivington,1  who  has  carefully  examined  a  small  number 
of  cases,  thinks  more  extended  observations  would  be  likely  to  estab- 
lish the  existence  of  valves  at  the  orifices  of  both  the  right  and  left 
spermatic  veins  with  few  exceptions.  When  no  valves  exist  at  the 


1  Valves  of  the  Renal  Veins.     Journal  of  Anatomy  and  Physiology.     Vol.  VI. 


40  Frozen  Sections  of  a  Child. 

opening  of  the  left  spermatic  vein,  some  are  generally  found  near  it 
in  the  renal  vein.  He  found  several  instances  of  valves  at  or  neat: 
the  mouths  of  the  renal  veins  and  also  of  the  semilunar  fold  at  the 
lower  part  of  the  orifice  of  the  renal  vein  which  had  been  described 
before. 

Perhaps  the  most  important  feature  of  this  plate  is  the  view  of  the 
beginning  and  the  end  of  the  duodenum.  A  probe  is  passed  through 
the  pylorus.  The  thickening  of  the  muscular  layer  at  this  point  is 
very  striking.  The  opening  looks  almost  directly  backward.  The 
inferior  wall  of  the  duodenum  is  seen  in  this  plate,  but  the  cavity  of 
the  gut  rises  above  this  level  as  it  passes  between  the  gall-bladder 
and  the  head  of  the  pancreas.  It  then  turns  abruptly  downward,  and 
we  see  it  descending  between  the  gall-bladder  and  the  renal  vein. 
In  PLATE  X.  it  is  seen,  having  again  changed  its  direction,  running 
from  right  to  left  across  the  body  of  the  second  lumbar  vertebra  be- 
hind the  mesentery,  in  which  branches  of  the  superior  mesenteric 
artery  are  seen.  It  then  rises  and  inclines  forward  to  end  in  the  fold 
shown  in  PLATE  IX.  Thus  we  see  both  ends  of  the  duodenum  at 
about  the  same  level.  They  are  both,  to  a  certain  extent,  fixed 
points  ;  the  former  being  attached  to  the  stomach,  and  the  latter  sus- 
pended by  muscular  fibres  coming  from  the  cceliac  axis  and  the  cms 
of  the  diaphragm.  The  remainder  of  the  duodenum — to  wit,  all  but 
the  ends — is  pretty  freely  movable.  It  has  been  compared  to  a  horse- 
shoe, and  to  a  ring  not  quite  completed.1  The  plates  show  its  peri- 
toneal relations  very  fairly.  In  PLATE  IX.  we  see  its  first  part  cov- 
ered by  peritoneum  on  the  right  from-  the  general  cavity,  on  the  left 
from  the  lesser,  both  being  prolonged  from  the  front  and  the  back  of 
the  stomach  respectively.  In  PLATE  X.  the  peritoneum  is  seen  cov- 
ering the  front  of  the  transverse  portion,  excepting  where  it  is  behind 
the  mesentery.  On  the  left,  it  begins  to  be  surrounded  again  by  the 
peritoneum.  In  PLATE  IX.  the  colon  appears  in  a  mass  of  fat  between 
the  liver  and  spleen.  Its  apparently  minute  size  and  the  absence  of 
all  peritoneal  attachment  will  be  accounted  for  when  it  is  known  that 
the  very  highest  point  of  the  colon  is  barely  touched.  A  considerable 
part  of  the  pancreas  appears  in  this  plate,  in  front  of  the  first  lumbar 
vertebra.  The  head  lies  against  the  duodenum,  the  tail  in  front  of  the 
left  kidney.  The  peritoneum  passes  over  its  anterior  surface. 


'  Braune  :  Archiv  fur  Anatomie  und  Entwickelungsgeschichte.      1877. 


».!• 


V 


•^ 


\ 


PLATE  X. 

r  I  ^HE  slice  above  this  section,  as  well  as  the  remainder,  are  rather 
JL  thicker  than  those  through  the  upper  part  of  the  body ;  thus, 
the  level  of  this  plate  is  nearly  2.3  ctm.  below  that  of  the  preceding. 
The  second  lumbar  vertebrae  is  divided  in  its  lower  half.  The  carti- 
lages of  tVie  eleventh  and  twelfth  ribs  are  cut  near  their  tips  ;  they  are 
now  quite  out  of  the  thoracic  region,  and  end  between  the  abdominal 
muscles.  The  cartilage  of  the  tenth  rib  is  missed  on  the  right  by  a 
hair's  breadth.  The  lumbar  region  of  the  spine  has  a  mean  length  in 
the  adult  of  17.2  ctm.,  forming  29.84  per  cent,  of  the  movable  portion 
of  the  spine.  The  intervertebral  disks  represent  44.6  per  cent,  of  it. 
The  diameter  of  the  abdomen  from  before  backward  is  less  compared 
with  the  breadth  than  in  the  last  plate,  probably  on  account  of  the 
small  piece  of  the  liver  that  is  found  in  this  section.  The  lowest  part 
of  the  stomach  lies  in  front,  and  on  either  side  of  it  a  piece  of  the 
colon  is  seen.  A  piece  of  the  colon  appears  by  each  kidney.  The 
transverse  colon,  as  may  be  inferred  from  this  plate,  is  a  loop  or  fes- 
toon attached  at  two  points  to  the  back  of  the  abdomen,  and  hanging 
both  downward  and  forward.  The  relations  of  the  peritoneum  to  the 
colon  are  interesting,  though  more  important  in  other  parts  of  it  than 
in  those  shown  in  this  plate.  The  parts  of  the  ascending  and  descend- 
ing colon  lying  by  either  kidney  are  but  partially  covered.  The  great 
omentum  is  seen  prolonged  from  the  left  of  the  stomach  across  a  piece 
of  the  transverse  colon.  Let  it  be  remembered  that  the  cavity  of  the 
omentum  is  behind  the  stomach  and  above  the  transverse  meso-colon, 
and  then  is  prolonged  downward  in  a  fold  of  peritoneum  attached  to 
the  stomach  above  and  passing  over  the  front  of  the  colon,  and  in- 
separably united  to  the  upper  anterior  surface  of  the  meso-colon,  from 
which  it  originally  was  distinct.  The  descending  portion  of  the 
omentum  was  necessarily  drawn  in  a  conventional  manner,  which 
makes  it  appear  thicker  than  it  really  is  at  this  age.  It  may  become 
6 


42  Frozen  Sections  of  a  Child. 

loaded  with  fat  in  the  adult.  The  mesentery  lies  in  front  of  the  du- 
odenum, just  below  the  origin  of  the  transverse  meso-colon,  and  con- 
tains the  greater  part  of  the  ramifications  of  the  superior  mesenteric 
artery  in  its  folds. 

The  kidneys  present,  in  this  plate,  pretty  nearly  the  reverse  of 
their  relative  sizes,  as  shown  in  PLATE  IX.  The  right  one  is  here 
divided  at  about  its  middle,  and  the  left  one  below  it.  PLATE  VIII. 
shows  the  left  kidney  at  the  disk  between  the  eleventh  and  twelfth 
vertebrae,  in  an  angle  bounded  by  the  stomach  in  front  and  the  spleen 
on  the  left.  The  diaphragm  and  pleura  overlap  it  behind.  The 
left  kidney  is  the  higher,  though  PLATE  VIII.  unfortunately  makes  it 
appear  a  little  higher  than  it  should,  owing  to  the  obliquity  of  the  cut. 
The  right  one,  which  is  seen  alone  in  PLATE  XL,  is  clearly  the  lower. 
The  left  kidney  is  said  to  reach  to  the  upper  border  of  the  eleventh 
rib,  and  the  right  half  a  rib's  breadth  lower.  It  is  very  possible  that 
the  difference  between  the  two  is  more  marked  in  this  case,  and  that 
the  left  one  is  a  trifle  higher ;  but  this  account  is  not  far  wrong. 
About  half  of  the  right  kidney  appears  below  the  ribs,  and  rather 
less  of  the  left.  The  diaphragm,  as  already  stated,  covers  the  back 
of  their  upper  ends,  and  lower  down  they  rest  against  the  quadratus 
lumborum  behind  and  the  psoas  on  their  inner  side.  The  peritoneum 
rests  against  them  to  a  varying  extent,  but  normally  never  surrounds 
them.  A  kidney  may  be  movable  from  either  one  of  two  causes  :  ist, 
it  may  have  a  peritoneal  covering  and  a  true  mesentery ;  2d,  and, 
more  commonly,  the  areolar  tissue  that  surrounds  it  may  become  less 
firm  than  before,  especially  by  the  loss  of  fat,  and  thus  leave  the  kid- 
ney without  support. 

The  three  muscular  layers  bounding  the  sides  of  the  abdomen 
present  some  features  that  call  for  notice.  It  is  interesting  to  see 
that  the  external  and  internal  oblique  run  in  the  same  direction,  and 
are  in  the  same  planes  as  the  external  and  internal  intercostals,  respec- 
tively, and  that  the  triangularis  sterni  appears  to  be  a  continuation  of 
the  transversalis.  As  to  the  action  of  these  muscles  and  the  purpose 
of  their  arrangement,  it  is  evident  that  they  protect  the  contents  of 
the  abdomen  more  effectually  than  if  their  fibres  all  ran  in  one  direc- 
tion. There  is,  I  think,  no  evidence  that  they  can  contract  indepen- 
dently, and  their  close  connection  makes  it  improbable.  They  are 
essentially  compressors  of  the  abdomen  ;  they  help  to  extrude  its  ex- 
cretions, and  they  are  sometimes  antagonists  of  the  diaphragm.  They 


Frozen  Sections  of  a  Child.  43 

assist  to  give  it  a  firm  support  for  contraction  by  steadying  the  tho- 
rax. Carried  further,  their  action  is  to  flex  the  body  forward,  and,  it 
may  be,  when  one  side  acts  alone,  to  twist  it. 

The  posterior  border  of  the  external  oblique  does  not  pass  off 
into  any  fascia,  but  is  a  distinct  line  running  from  the  last  rib  to  the 
crest  of  the  ilium,  forming  the  front  of  a  triangle,  the  base  of  which  is 
a  small  portion  of  the  crest,  the  posterior  border  being  formed  by  the 
front  edpfe  of  the  latissimus  dorsi.  This  is  the  triangle  of  Petit.  The 

o  o 

latissimus  may  reach  the  external  oblique,  or  even  overlap  it,  as,  I 
think,  is  the  case  on  the  left  side  of  PLATE  X.  In  either  case,  of 
course  the  triangle  does  not  exist ;  it  is  usually  to  be  found  in  adults, 
and  not  in  infants.  Lesshaft1  found  it  eighty-four  times  in  one  hun- 
dred and  eight  bodies  of  adults,  and  only  nine  times  in  thirty-five 
bodies  of  new-born  children  and  foetuses.  The  floor  of  this  triangle 
is  formed  by  the  posterior  fibres  of  the  internal  oblique.  It  is  a  weak 
point  in  the  abdominal  wall.  The  muscular  belly  of  the  great  erector 
spinae  is  seen  in  this  plate,  but  more  developed  in  the  following.  It 
is  a  very  powerful  muscle,  and  with  the  gluteus  maximus  is  the  most 
important  in  maintaining  the  erect  position.  The  nomenclature  of 
English  anatomists  is  very  clumsy — that  of  Henle  very  simple  and 
explanatory  instead  of  confusing.  In  English  we  have  it  divided  into 
seven  pieces.  The  innermost  is  the  spinalis  dorsi,  which  runs  be- 
tween the  spines  of  the  upper  lumbar  and  lower  dorsal  vertebrae  and 
those  of  the  upper  dorsal  region.  Then  comes  the  longissimus  dorsi, 
prolonged  by  the  transversalis  cervicis  to  the  neck,  and  that,  in  turn, 
by  the  trachelo-mastoid  to  the  head.  Outside  of  this  column  lies  the 
ilio-costalis,  its  accessory  muscle,  and  finally  the  cervicalis  ascendens, 
ending  at  the  transverse  processes  of  the  neck.  Henle  very  properly 
omits  the  spinalis  dorsi,  treating  it  as  a  separate  muscle.  There 
then  remains  the  great  muscular  mass  derived  from  the  ilium,  the 
lumbar  fascia,  and  sacrum,  which  divides  into  two  main  columns,  com- 
posed— the  inner  of  the  longissimus  dorsi,  cervicis,  and  capitis ;  the 
outer  of  the  ilio-costalis  lumborum,  dorsi,  and  cervicis,  respectively. 


1  Die  Lumbalgegend  in  anatomisch-chirurgischer  Hinsicht.     Archiv  fur  Anatomic,  Phy- 
siologic und  wissenschaftliche  Medicin.     (Reichert  and  Du  Bois  Reymond.)  1870. 


*  f  "*     •  •>«•»    "V*»   "      r 

•    • .  *  .       *      J    *•   •  *      -1 

***     ">   *  ,*c  J»***S  *        *     <,*"  "* 


PLATE    XI. 

THIS  section  is  about  2.4  ctm.  below  the  last.  It  passes  through 
the  intervertebral  disk  between  the  third  and  fourth  lumbar 
vertebrae,  showing  the  spine  and  arch  of  the  former,  embraced  by  the 
articular  processes  of  the  latter.  The  breadth  of  the  vertebral  column 
is  apparent.  The  spinal  cord  has  come  to  an  end  in  the  thickness  of 
the  slice  above,  probably  near  the  top  of  the  third  lumbar.  At  birth 
it  is  said  to  approach  the  fourth  lumbar,  but  owing  to  the  more  rapid 
growth  of  the  spinal  column,  it  subsequently  is  not  found  so  low.  In 
man  it  ends  at  about  the  lower  border  of  the  first,  and  in  woman, 
perhaps  half  way  down  the  second.  Nevertheless,  according  to 
Ravenel,1  the  female  cord  is  relatively  shorter  than  the  male.  In  this 
subject  the  cord  is  still  relatively  long.  In  the  adult  the  origins  of  the 
nerves  of  the  lumbar  plexus  are  opposite  the  space  from  the  eleventh 
to  the  twelfth  dorsal  spine,  or  a  little  lower,  and  those  of  the  sacral 
plexus  extend  from  the  latter  point  to  the  first  lumbar  spine.  They 
are,  of  course,  lower  here,  but  they  cannot  easily  be  placed. 

The  umbilicus  is  rather  below  the  level  of  this  cut,  opposite  the 
fourth  lumbar.  Holden  places  it  opposite  the  third  lumbar,  and 
Luschka  opposite  the  lower  edge  of  that  vertebra.  If  I  may  differ 
from  such  authorities,  I  should  say  that  it  is  more  frequently  below 
than  above  the  disk  between  the  third  and  fourth  lumbar  vertebrae, 
and  near  the  level  of  the  highest  point  of  the  crest  of  the  ilium.  I  do 
not  think  that  in  this  instance  it  is  far  from  the  adult  position,  though 
still  rather  lower. 

The  great  omentum  lies  in  front  of  the  intestines.  Two  pieces 
of  the  mesentery  are  seen,  one  of  which  runs  transversely,  and  the 
other  forward  toward  the  right  rectus.  In  the  right  anterior  part  of 
the  abdomen  there  is  an  appearance  somewhat  resembling  a  diver- 
ticulum,  such  as  is  sometimes  found  in  the  lower  part  of  the  ilium.  It 
is  not  one,  however,  but  a  true  invagination  of  the  intestine.  There 


Zeitschrift  fur  Anatomic  and  Entwickelungsgeschichte.     Band  II. 


46  Frozen  Sections  of  a  Child. 

is  no  sign  of  inflammation  around  it.  It  is  probable  that  small  invagi- 
nations  occur  not  rarely  in  children,  and  reduce  themselves  without 
giving  rise  to  symptoms. 

The  caecum  is  seen  in  this  plate  lying  on  the  right  side  of  the  ab- 
domen. More  than  one-half  of  it  is  below  the  surface  of  this  section, 
so  that  we  may  with  sufficient  accuracy  say  that  it  is  on  a  level  with 
the  umbilicus.  The  ilium  lies  on  the  left  of  the  caecum  as  it  descends 
to  open  into  it  lower  down.  The  vermiform  appendix,  which  arises 
from  the  rear  of  the  caecum  at  a  still  lower  point,  appears  behind  it. 
It  pursues  a  twisted  course,  in  the  main,  upward  and  inward.  To  un- 
derstand this  position  of  the  caecum,  we  must  remember  that  in  the 
early  part  of  fcetal  life  the  caecum,  which  is  a  little  diverticulum  of 
the  intestine,  lies  below  the  liver  near  the  median  line.  The  future 
large  intestine  runs  from  this  point  to  the  left,  and  then  downward. 
Gradually,  however,  the  caecum  moves  to  the  right  above  the  mesen- 
tery, thus  forming  the  transverse  colon.  It  then  descends  along  the 
right  side  of  the  abdomen,  forming  the  ascending  colon.  According  to 
Dr.  Allen  Thomson,1  the  parts  are  in  the  same  positions  as  in  the  adult 
in  the  fourth  or  fifth  month  of  fcetal  life.  Kolliker2  states  that  they 
descend  toward  the  iliac  fossa  in  the  latter  half  of  fcetal  life.  It  is  evi- 
dent that  in  this  child  the  caecum  has  made  very  little  progress  in  its 
descent  from  the  right  hypochondrium.  My  observations  lead  me  to 
believe  that  the  wanderings  of  the  caecum  are  not  completed  as  soon 
as  these  authorities  state.  I  doubt  very  much  if,  as  a  rule,  it  has 
reached  its  permanent  position  at  birth,  and  think  that  not  very  rarely 
it  does  not  reach  it  for  a  year  or  two  afterward. 

The  ascending  colon,  what  there  is  of  it,  runs  upward  in  front  of 
the  right  kidney,  in  the  angle  between  it  and  the  lowest  part  of  the 
liver,  as  is  shown  in  PLATE  X.  It  rises  a  little  above  this  level,  but 
soon  turns  down  to  reappear  in  the  same  plate  as  the  transverse 
colon,  which  is  traced  to  the  side  of  the  stomach.  It  reappears  on 
the  left  of  that  organ,  and  rises  higher  than  on  the  right.  Its  highest 
point  is  just  opened  in  PLATE  IX.  beside  the  beginning  of  the  cartilage 
of  the  ninth  rib.  The  descending  colon  is  seen  in  Plate  X.  outside  of 
the  kidney.  It  follows  the  surface  of  the  organ,  so  that  below  the 
kidney  in  PLATE  XI.  we  see  it  further  in,  just  opposite  the  border  of 
the  erector  spinae.  In  PLATE  XII.  it  is  making  its  way  forward,  lying 

1  Quain's  Anatomy.     Eighth  edition.     Vol.11.  s  Entwickelungsgeschichte. 


Frozen  Sections  of  a  Child.  4; 

in  the  angle  between  the  psoas  and  iliacus.  In  the  next  plate  it  has 
reached  the  abdominal  walls,  and  a  little  later  begins  to  form  the 
sigmoid  flexure,  which  we  will  leave  for  the  present.  Two  points  of 
comparison  with  the  adult  arrangement  must  be  mentioned.  The 
right  colon  of  the  adult  passes  in  front  of  the  right  kidney,  as  is  the 
case  with  its  rudiment  here.1  The  left  colon  on  the  other  hand,  lies 
on  the  outer  side  of  the  left  kidney.  The  transverse  colon  in  the 
adult  not  uncommonly  hangs  down  in  front  as  low  as  the  umbilicus. 
Both  the  ascending  and  descending  colon  are  but  partly  covered  by 
peritoneum  at  the  level  of  PLATE-  X.  The  descending  one,  however, 
is  more  covered  in  the  next  plate,  and  has  a  true  mesentery  in  the 
iliac  fossa.  The  relation  of  the  peritoneum  to  the  colon,  especially 
on  the  left,  is  of  much  surgical  importance.  The  extent  to  which  the 
gut  is  covered  varies  extremely,  and  at  all  ages.  Lesshaft  found  that 
on  the  average  the  left  colon  had  a  mesentery,  usually  a  very  short 
one,  once  in  six  subjects. 

The  lumbar  fascia  deserves  notice.  The  superficial  layer  is  a 
very  strong  diamond-shaped  aponeurosis,  extending  high  up  in  the 
dorsal  region,  down  toward  the  coccyx,  and  laterally  on  to  the  ilia. 
The  latissimus  dorsi  arises  from  it  above,  as  does  also  the  serratus 
inferior,  and  the  gluteus  maximus  springs  from  it  below.  The  erec- 
tor spinse  which  it  bridges  over  has  a  part  of  its  origin  from  the  deep 
surface  of  this  fascia.  In  short,  the  muscles  that  straighten  the  body, 
by  drawing  both  the  upper  and  under  halves  backward,  spring  from 
it.  This  arrangement  shows  the  necessity  of  the  thickness  of  the 
anterior  portion  of  the  capsule  of  the  hip-joint.  At  the  outer  margin 
of  the  erector  spinae  the  fascia  above  described  is  joined  by  the  mid- 
dle layer  of  the  lumbar  fascia,  which  runs  to  the  transverse  processes 
of  the  lumbar  vertebrae.  This  is  continuous  with  the  transversalis 
muscle,  and  some  fibres  of  the  internal  oblique  arise  from  its  posterior 
surface.  In  front  of  this  fascia  lies  the  quadratus  lumborum,  which 
extends  beyond  the  outer  edge  of  the  erector.  Covering  the  anterior 
surface  of  the  quadratus  is  the  inner  layer  of  the  lumbar  fascia,  ex- 
tending from  the  roots  of  the  transverse  processes  outward  to  join 
also  the  transversalis  muscle.  Below  it  is  attached  to  the  crest  of 
the  ilium,  and  it  ends  above  as  the  ligamenta  arcuata.  The  superfi- 
cial layer  of  the  lumbar  fascia,  which  is  very  dense  is  shown  in  PLATE 
XL,  turning  round  the  outer  borders  of  the  erectores. 

1  Lesshaft,  loc.  cit.     This  rule  does  not  seem  to  be  quite  without  exceptions. 


,')•• 


"X 


PLATE   XII. 

THIS  section,  about  2.4  ctm.  below  the  last,  is  not  quite  even,  the 
right  side  being  the  higher.  Though  the  difference  is  slight, 
it  is  sufficient  to  occasion  considerable  discrepancy  between  the  lateral 
halves  which  otherwise  would  be  nearly  symmetrical.  The  right 
ilium,  of  course,  seems  not  only  shorter,  but  more  cartilaginous  than 
the  other.  The  fifth  lumbar  vertebra  shows  an  asymmetry  that  is  really 
only  apparent,  for  on  the  left  it  is  struck  at  its  prominent  lower  bor- 
der, and  on  the  right  in  the  concavity  which  its  surface  presents.  The 
articular  process  of  the  sacrum  appears  on  the  left,  but  not  on  the 
right.  The  fifth  lumbar  is  shown  enclosed  by  the  ilia,  which  project 
above  it  and  behind  all  of  it  except  the  spinous  process.  The  ilio- 
lumbar  ligament,  running  from  the  transverse  process  of  the  last  lum- 
bar to  the  crest  of  the  ilium,  is  above  this  section,  but  strong  bands 
of  fibres,  running  more  or  less  obliquely  between  different  points  of 
the  vertebral  column  and  the  ilium,  are  seen  on  both  sides.  It  is  well 
to  remember  that  the  spine  of  the  fourth  lumbar  vertebra  is  on  a  level 
with  the  highest  point  of  the  crest  of  the  ilium. 

Having  reached  the  lower  end  of  the  movable  portion  of  the 
spinal  column  something  may  be  said  of  its  curves,  and  first  of  those 
in  the  adult.  There  is  no  absolute  standard ;  all  people  do  not  have 
the  same  curve.  Apart  from  the  peculiarities  of  the  figure  of  each 
individual,  the  curve  is  modified  by  the  profession,  the  age,  various 
diseases,  by  fatigue,  and  by  position.  Mr.  Wood1  gives  a  rule  which, 
though  it  is  not  confirmed  by  my  observations,  is,  no  doubt,  approxi- 
mately correct,  and  is  certainly  simple :  it  is  that  a  line  from  the  cen- 
tre of  the  body  of  the  axis  to  that  of  the  last  lumbar  vertebra  at  its 
articulation  with  the  sacrum  passes  through  the  body  of  the  first  dor- 

1  Topographical  Relations  of  Arch  of  Aorta,  etc.     Journal  of  Anatomy  and  Physiology. 
Vol.  III. 

7 


50  Frozen  Sections  of  a  Child. 

sal  and  second  lumbar.  He  adds  that  it  "  would  indicate  the  line  of 
gravity  of  the  head  and  trunk  in  a  perfectly  upright  and  balanced 
position,  traversing  the  pelvis  midway  between  the  cotylo-femoral 
joints  and  falling  between  the  bases  of  support."  It  should  be  stated 
that  these  remarks  of  Mr.  Wood  apply  especially  to  the  young  adult 
male.  Henle's  rule  that  the  middle  of  a  line  from  the  top  of  the  atlas 
to  the  end  of  the  coccyx  is  opposite  the  eleventh  dorsal,  that  the  first 
quarter  ends  opposite  the  lower  border  of  the  third  dorsal,  and  the 
third  quarter  opposite  the  lower  edge  of  the  fourth  lumbar,  has  seemed 
to  me  remarkably  accurate.  At  birth  the  spinal  column  is  very  nearly 
straight ;  indeed,  the  line  of  the  spinous  processes  may  be  perfectly 
so,  but  the  bodies  of  the  vertebrae  show  a  curve  in  the  cervical  and 
dorsal  regions.1  According  to  Ballandin 2  the  normal  curve  of  the 
neck  does  not  appear  till  the  third  month  after  birth.  It  soon  be- 
comes more  stable,  as  does  also  the  dorsal  one.  The  lumbar  curve 
does  not  appear  till  the  child  begins  to  walk,  and  it  is  stated  that  it 
can  be  obliterated  by  traction  on  the  detached  spine  till  the  twentieth 
year.  Ballandin's  views  on  the  production  of  the  lumbar  curve  are 
interesting  and  plausible,  and  agree  well  with  what  was  said  in  the 
last  chapter  concerning  the  powerful  muscles  of  the  back  that  main- 
tain the  upright  position  and  the  strength  of  the  front  part  of  the  cap- 
sule of  the  hip.  Ballandin  states  that  if  a  very  young  child  be  laid  on 
its  back,  with  the  lumbar  and  dorsal  spinous  processes  resting  on  the 
table,  the  legs  naturally  assume  the  position  of  outward  rotation,  the 
knees  usually  being  somewhat  bent.  If  the  knees  are  brought  to- 
gether, they  at  once  spring  up  farther  from  the  table  ;  but  if  they  be 
pressed  down  and  made  to  touch  it,  the  abdomen  becomes  prominent 
and  the  spinal  column  bends  forward  in  the  lumbar  region.  The 
same  thing  occurs  after  the  removal  of  the  viscera,  and  can  be  shown 
to  depend  on  the  shortness  of  the  ilio-femoral  ligaments.  As  the  child 
learns  to  stand  and  walk,  and  the  great  erector  muscles  are  raising  the 
body,  they  are  constantly  resisted  by  this  ligament  (assisted  probably 
by  the  iliacus  and  psoas),  and  thus  the  obliquity  of  the  pelvis  is  in- 
creased and  the  lumbar  region  of  the  spine  pulled  forward. 

Returning  to  this  plate  we  find  little  worthy  of  notice  in  the  ab- 
dominal viscera.    The  colon  is  seen  between  the  left  iliacus  and  psoas, 


1  Bouland  :  Robin's  Journal  de  FAnatomie  et  de  la  Physiologic.      1872. 
'•  Virchow's  Archives.     Vol.  LVII. 


Frozen  Sections  of  a  Child.  51 

the  omentum  is  still  in  front,  and  the  remainder  of  the  space  is  filled 
by  folds  of  small  intestine,  which  are  distended  on  the  left  and  con- 
tracted on  the  right.  The  psoas  makes  a  bold  projection  on  either 
side  of  the  vertebra.  Nerves  of  the  lumbar  plexus  are  seen  within  it. 
A  considerable  amount  of  fat  lies  between  the  psoas  and  iliacus  be- 
hind the  peritoneum.  The  aorta  has  divided  in  the  thickness  of  the 
slice  above  this  plate,  presumably  at  about  the  normal  position  oppo- 
site the  middle  of  the  fourth  lumbar  vertebra.  It  is  much  more  likely 
to  divide  below  than  above  this  point.  The  common  iliac  artery  and 
vein  are  seen  on  the  right,  while  on  the  left,  at  a  somewhat  lower 
level,  the  external  and  internal  iliac  arteries  lie,  just  after  their  origin, 
in  front  of  the  common  iliac  vein,  which  is  running  very  obliquely  at 
this  point.  The  iliac  arteries  usually  divide  near  the  lower  border 
of  the  last  lumbar  vertebra.  The  right  one  is  usually  the  longer. 
Their  relations  to  veins  differ  materially.  At  their  lower  ends  each 
has  the  vein  at  its  inner  side,  but  the  left  vein  inclines  to  the  right,  as 
does  also  the  right  one,  which  gets  behind  its  artery,  and  the  two 
unite  to  form  the  vena  cava  behind  the  right  iliac  at  a  point  below  the 
bifurcation  of  the  aorta. 

Nothing  has  been  said  of  the  ureters,  which,  indeed,  call  for  little 
comment  till  they  reach  the  bladder.  They  descend  along  the  psoas 
behind  the  peritoneum.  In  this  plate  they  are  still  on  the  outside  of 
the  iliac  vessels,  which  they  usually  cross  near  the  division  of  the 
common  iliacs.  In  PLATE  XIII.  they  pass  near  the  outer  angles  of 
the  promontory  of  the  sacrum.  It  is  not  uncommon  for  the  ureter  to 
be  double  at  its  origin,  but  the  two  roots  almost  always  unite  before 
opening  into  the  bladder. 


PLATE    XIII. 


0* 


PLATE  XIII. 

THIS  is  an  interesting  but,  at  first,  a  very  confusing  section.  It  is 
nearly  2.5  ctm.  below  the  last,  and  rather  higher  on  the  right 
than  on  the  left.  The  very  curious  view  of  the  sacrum  suggests  that 
the  cut  slants  backward,  but  it  does  so,  at  most,  to  a  very  slight  ex- 
tent. The  anterior  superior  spinous  processes  of  the  ilia  are  struck 
pretty  evenly  on  both  sides.  The  articular  surface  of  the  ilium  is 
separated  from  the  expanded  portion  that  forms  the  wall  of  the  false 
pelvis  by  a  well-marked  angle  which  represents  the  beginning  of  the 
ilio-pectineal  line  at  the  edge  of  the  promontory  of  the  sacrum.  On 
account  of  the  relations  of  the  great  sacral  nerves  to  the  vertebrae  it 
will  be  convenient  to  consider  both  together.  The  fifth  lumbar  nerve 
is  seen  in  PLATE  XII.  leaving  the  spinal  canal ;  it  is  seen  again  in  this 
plate,  close  by  the  promontory,  as  the  lumbo-sacral  cord,  a  name  it 
assumes  after  it  is  joined  by  a  branch  from  the  fourth  lumbar,  which 
probably  has  occurred  before  it  has  reached  this  level.  The  first 
sacral  nerve  appears  just  as  it  leaves  the  anterior  sacral  foramen. 
The  bodies  and  the  lateral  masses  of  the  second  and  third  sacral  verte- 
brae are  seen  farther  back,  cut  very  obliquely.  The  second  sacral  nerve 
lies  in  the  foramen  between  them.  The  arch  of  the  third  vertebra  is 
very  accurately  hit.  The  third  sacral  nerve,  much  smaller  than  the 
preceding  ones,  lies  in  the  canal,  which  it  is  just  about  to  leave.  The 
sacral  plexus,  be  it  remembered,  is  formed  by  the  lumbo-sacral  cord, 
the  first  three  sacral  nerves,  and  a  branch  of  the  fourth.  It  is  a  broad 
nervous  band,  reaching  toward  the  lower  part  of  the  great  sacro-sciatic 
foramen,  which  its  direct  continuation,  the  great  sciatic  nerve,  leaves 
below  the  pyriformis.  The  view  of  the  process  of  ossification  is  a  very 
instructive  one.  The  inclination  of  the  pelvis  must  be  very  consider- 
able to  account  for  this  view  of  the  sacrum.  To  place  the  pelvis  in 
its  proper  position,  the  normal  conjugata  of  Hermann  Meyer  should 
form  an  angle  of  30°  with  the  horizon.  This  conjugata  is  a  line  run- 


54  Frozen  Sections  of  a  Child. 

ning  from  the  top  of  the  symphysis  to  a  transverse  line  across  the 
body  of  the  third  sacral  vertebra.  The  anterior  superior  spines  of 
the  ilia  should  be  in  the  same  vertical  plane  as  the  spines  of  the  pubes, 
and  perhaps  even  a  little  in  front  of  it.  Very  different  views  are  ex- 
pressed as  to  the  difference  in  the  curve  of  the  male  and  female 
sacrum.  I  agree  with  Ward  that  the  male  sacrum  is  the  more  curved, 
and  that  the  curve  is  more  regular.  The  female  sacrum  is  more  dis- 
tinctly divided  into  two  parts,  the  upper  of  which  is  smooth  and  the 
lower  curved,  by  the  line  just  mentioned,  which  crosses  the  third  ver- 
tebra. This  line,  I  believe,  was  first  described  by  Hermann  Meyer. 
It  is  not  rare  to  find  the  sacrum  composed  of  six  vertebrae.  Some- 
times it  seems  as  if  there  were  an  extra  piece,  intermediate  in  charac- 
ter and  position,  between  the  lumbar  and  sacral  vertebrae,  or  the 
number  of  the  latter  is  evidently  increased.  Bacarisse1  gives  a  rule  for 
determining  whether  a  mutilated  sacrum  is  one  of  five  or  six  pieces.  If 
a  line  connecting  the  lower  ends  of  the  auricular  surfaces  pass  above 
the  middle  of  the  third  vertebra,  there  are  five  pieces ;  if  below  it, 
six.  The  sacro-iliac  synchondrosis  is  one  of  the  strongest  in  the 
body,  but  great  additional  strength  is  gained  by  the  very  strong  liga- 
ments passing  from  the  sides  of  the  sacrum  and  the  back  of  the  ilia, 
so  as  to  oppose  the  separation  of  the  latter  by  the  weight  of  the  body 
on  the  sacrum.  The  psoas  and  iliacus  lying  on  the  inner  side  of  the 
ilium  encroach  a  good  deal  on  the  abdominal  cavity.  The  tendon  of 
the  psoas,  at  first  inside  the  muscle,  has  now  reached  its  outer  border. 
It  receives  fibres  from  the  iliacus  as  well  as  from  the  psoas.  The  vis- 
cera that  are  shown  in  this  plate  are,  for  the  most  part,  either  in  or 
above  the  cavity  of  the  true  pelvis.  The  descending  colon,  and  some 
folds  of  the  small  intestine,  occupy  the  iliac  fossae,  and  the  anterior 
wall  of  the  abdomen  is  distended  so  as  to  project  in  front  of  the 
pubes.  Most  of  the  remaining  cavity  is  occupied  by  the  sigmoid  flexure 
of  the  colon.  The  point  where  the  descending  colon  ends  and  the 
sigmoid  flexure  begins  is  not  a  very  definitely  placed  one.  In  this 
instance  it  is  in  the  thickness  of  the  slice  below  PLATE  XIII.  We  see 
the  descending  colon  cut  transversely.  It  passes  to  the  right,  turns 
suddenly,  and  reappears  behind  the  left  rectus  as  the  sigmoid. 
Luschka  places  the  beginning  opposite  the  highest  point  of  the  crest 
of  the  ilium,  where  the  colon  begins  to  be  surrounded  by  peritoneum. 

1  Inaugural  Thesis.     Paris.    1873. 


Frozen  Sections  of  a  Child.  55 

It  must  be  remembered  that  the  whole  descending  colon  may  be  so 
covered,  and  there  seems  no  reason  for  having  the  change  of  name 
precede  the  change  of  direction.  The  sigmoid  flexure  in  this  case 
forms  a  very  respectable  "  S/'  ending  opposite  the  left  sacro-iliac  syn- 
chondrosis,  where  the  rectum  begins.  This  flexure  is  attached  to  a 
pretty  long  mesentery  that  allows  it  to  move  very  freely.  Its  posi- 
tion varies  not  only  with  the  degree  of  its  distention,  but  with  that 
also  of  the  bladder  and  of  the  other  folds  of  intestine.  It  may  be 
found  in  the  right  iliac  fossa.  In  new-born  children  it  very  frequently 
extends  into  the  right  inguinal  region  ;  indeed,  it  is  always  there  at 
that  age  according  to  some  authorities. 

The  ovaries  are  seen  in  this  plate  occupying  very  different  posi- 
tions from  those  they  assume  later.  The  right  one  is  situated  at  the 
margin  of  the  true  pelvis  opposite  the  outer  part  of  the  promontory. 
The  left  one  is  much  farther  forward,  opposite  the  external  iliac  ves- 
sels and  entirely  above  the  true  pelvis,  for  this  section  strikes  its 
lower  end.  They  are  both  placed  with  the  end  nearest  the  uterus 
below,  and  with  their  flat  surfaces  looking  sideways.  They  are  cov- 
ered by  a  fold  of  peritoneum.  The  ovaries,  in  fact,  are  descending 
into  the  pelvis  in  a  manner  perfectly  analogous  to  the  descent  of  the 
testes,  only  in  a  different  direction.  In  the  adult  the  ovaries  are  in 
the  true  pelvis.  It  is  very  doubtful  if  they  are  always  in  the  same 
position. 

The  right  external  iliac  artery  appears  much  larger  than  the  left, 
which  is  probably  due  to  the  injection  having  been  made  from  the 
right  femoral.  The  branches  of  the  internal  iliac  vessels  are  much 
behind  them,  making  their  way  downward  to  the  back  of  the  pelvis. 
The  gluteal  muscles  are  well  shown,  but  require  no  special  comment. 


$** 


$>* 


PLATE  XIV. 


^HE  plane  of  this  section  is  about  2.2  ctm.  below  that  of  the  one 
JL    above.     It  passes  7  mm.  above  the  symphysis  of  the  pubis   and 
strikes  the  last  piece  of  the  sacrum.     It  is  higher  on  the  right  than  on 
the  left,  but  about  level  from  before  backward.     Hence  it  is  evident 
that,  in  this  case  at  least,  the  pelvis  has  reached  its  full   inclination. 
One  is  struck  by  the  length  of  the  antero-posterior  diameter  compared 
with  the  transverse  one  ;  but  sections  by  Braune,  Pirogoff,  and  Rudin- 
ger  show  very  nearly  the  same  proportions  in  similar  sections  of  the 
adult  pelvis.     The  prominence  of  the  front  of  the  abdomen,  though 
caused  in  part  by  the  distended  bladder,  is  due  even  more  to  the  ac- 
cumulation of  subcutaneous  fat  above  the  pubes.     At  least  half  the 
cavity  is  filled  by  the  bladder,  which  was  moderately  distended  with 
urine.     The  cut  divided  it  very  nearly  evenly.     It  is  not  pointed  above, 
as  in  infancy,  but  is  irregularly  globular  and  somewhat  compressed 
from  before  backward,  which  often  is  the  case  with  the  female  bladder, 
as  is  also,  according  to  Luschka,  the  lateral  asymmetry  which  is  seen 
in  this  instance.     The  lightly  shaded  part  of  the  bladder  shows  the 
place  at  which  it  bulges  forward  over  the  pubes.     The  summit  of  the 
bladder  is  at  the  anterior  border,  where  it  extends  upward  between 
the  intestines  and  the  abdominal  wall.      The  posterior  wall  of  the 
bladder  is  thicker  than  the  front  one.     The  lowest  point  is  at  the 
opening  of  the  urethra,  which  is  very  sudden,  if  the  expression   is 
allowable.     There  is  the  merest  trace  of  a  funnel-like  narrowing,  con- 
stituting the  so-called  neck  of  the  bladder.     This,  if  it  exist  at  all,  is,  at 
all  events,  much  less  developed  in  the  female  than  in  the  male.  Straws 
have  been  passed  through  the  terminations  of  the  ureters,  which  are 
not  themselves  visible,  as  they  open  in  the  posterior  wall  of  the  blad- 
der.    The  trigonum  vesicce  is  a  triangle  formed  by  the  openings  of  the 
ureters    and  the   urethra,  the  mucous   membrane  covering  it  being 
smooth  instead  of  in  folds,  as  elsewhere.  The  wall  below  it  is  thickened 


58  Frozen  Sections  of  a  Child 

by  muscular  fibres  from  the  ureters,  and  a  band  running  between  their 
orifices  may  cause  a  ridge  in  the  bladder.  Accounts  of  the  position 
of  the  trigonum  do  not  agree.  It  is  usually  described  as  being  at  the 
lowest  part  of  the  bladder,  its  posterior  angles  being  somewhat  raised. 
Richet,  however,  states  that  the  lowest  part  of  the  bladder  is  the 
"  bas  fond"  situated  behind  the  trigonum.  The  openings  of  the  ure- 
ters in  this  case,  however,  are  distinctly  in  the  posterior  wall.  In  an- 
other girl,  a  little  larger  than  this  one,  examined  also  by  frozen  sections, 
they  have  very  nearly  the  same  position.  In  a  boy  of  about  the  same 
age,  examined  by  opening  the  abdomen,  the  bladder  was  found  nearly 
empty,  and  the  trigonum  was  in  the  lower  wall,  though  the  ends  of  the 
ureters  were  higher  than  the  urethra.  There  was  a  pouch  formed  by 
the  posterior  wall  behind  the  ridge,  at  the  base  of  the  triangle.  It 
seemed  as  if  distention  of  the  bladder  would  have  raised  the  orifices 
of  the  ureters.  In  Braune's  sagittal  section  of  a  young  male  (twenty- 
one  years),  they  are  in  the  posterior  wall.  It  is  probable  that  this  is 
their  normal  position  in  youth,  and  that,  with  advancing  years,  they 
gradually  sink  lower,  especially  in  the  male,  in  whom  the  base  of  the 
bladder  is  larger,  and  in  whom  the  bladder  is  with  more  difficulty  com- 
pletely emptied  from  various  causes,  and  in  whom,  chiefly  on  account 
o£  the  enlarging  prostate,  a  depression  or  pouch  behind  the  trigonum 
is  very  frequently  developed  in  the  latter  part  of  life.  In  the  female, 
this  does  not'occur.  The  peritoneum  covering  the  bladder  approaches 
the  plane  of  this  section  very  closely  at  the  anterior  angles  of  the  or- 
gan, and  behind  it,  where  it  is  reflected  over  the  uterus.  In  the  median 
line  it  does  not  come  within  1.5  ctm.  of  the  pubes. 

This  plate  shows  the  lowest  part  of  the  body  of  the  uterus.  It  is 
not  over  two  centimeters  in  length,  measured  as  well  as  circumstances 
permit  along  the  posterior  surface.  It  is  less  expanded  at  the  upper 
portion  than  in  the  adult.  It  inclines  forward,  resting  against  the  back 
of  the  bladder.  The  broad  ligaments  are  seen  on  the  under  surface 
of  the  slice  above,  running  to  the  sides  of  the  pelvis.  The  Fallopian 
tubes  run  much  more  upward  than  in  the  adult,  so  that  the  ovaries 
are  seen  in  the  preceding  section.  The  folds  of  the  broad  ligament 
contain,  even  at  this  age,  many  veins  which  later  form  a  series  of  very 
rich  plexuses,  which  communicate  both  with  the  system  of  the  iliac 
veins,  and  also  by  the  plexus  pampiniformis  and  ovarian  veins,  with 
the  vena  cava  on  the  right  and  the  renal  vein  on  the  left.  These  veins 
may  become  largely  dilated  and  varicose,  forming  a  true  varicocele  in 


Frozen  Sections  of  a  Child.  59 

the  female.1  The  diagnosis  cannot  be  made  with  certainty,  but  it  is 
very  probable  that  this  state  would  account  for  some  of  the  obscure 
pains  felt  in  the  left  side  only  at  the  menstrual  period.  The  rectum  is 
described  elsewhere.  Suffice  it,  therefore,  to  say  that  it  is  struck  just 
as  it  is  completing  a  curve  with  its  convexity  to  the  right.  Below  the 
fold,  seen  on  the  left,  it  expands  to  its  greatest  dimensions.  This  plate 
shows  the  lowest  part  of  the  peritoneal  pouch  between  it  and  the  uterus, 
which  extends  here  as  in  the  adult,  behind  the  upper  part  of  the  vagina. 
The  distance  of  this  from  the  anus  is  in  this  subject  approximatively 
2.5  ctm.  According  to  Tillaux,  in  the  adult  male  this  distance  is  5  ctm. 
with  an  empty  bladder  and  6  ctm.  for  a  full  one.  There  may  be  a 
variation,  however,  of  2  ctm.  It  is  well  known  that  when  the  bladder 
is  distended,  a  greater  extent  of  it  lies  above  the  symphysis  uncovered 
by  peritoneum.  Dr.  Garson2  has  shown  that  a  distended  rectum  ma- 
terially changes  the  relations  both  of  the  bladder  and  of  the  perito- 
neum. His  observations  apply  only  to  the  male.  He  has  shown  that 
by  distending  the  rectum  the  bladder  may  be  pushed  bodily  upward, 
carrying  the  peritoneum  farther  from  the  symphysis,  and  raising  it  also 
between  the  bladder  and  rectum.  This  displacement  of  the  bladder 
is  due  to  stretching  of  the  urethra,  chiefly  in  the  prostatic  and  some- 
what in  the  membranous  portion. 

The  greater  and  the  lesser  sacro-sciatic  ligaments  are  seen  most 
distinctly  on  the  right  side.  The  latter  lies  inside  of  the  former.  With 
the  aid  of  the  muscles  they  supply  the  deficiency  in  the  walls  of  the 
pelvis  caused  by  the  sciatic  notch.  The  obturator  internus  is  seen  in- 
side the  pelvis,  in  the  chamber  formed  by  the  bone  and  the  obturator 
fascia.  A  mass  of  fat  occupies  the  ischio-rectal  fossa  between  this  and 
the  pelvic  fascia  which  passes  to  the  sides  of  the  bladder,  vagina,  and 
rectum.  The  left  ischium  is  divided  just  at  the  spine,  to  which  the 
lesser  ligament  separating  the  two  foramina  is  attached.  The  pudic 
artery  and  nerve  (the  latter  drawn  rather  large)  are  seen  as  they  turn 
round  it.  The  glutei  muscles  are  shown  most  clearly  on  the  right.  On 


1  Some  years  ago,  while  injecting  the  system  of  the  vena  cava  inferior  from  the  common 
iliac  vein  in  a  woman  of  at  least  middle  age,  I  was  surprised  to  see  a  very  rich  plexus  of  veins 
appear  in  the  left  broad  ligament  and  send  a  branch  across  the  uterus.  I  found  that  this  had 
occurred  by  the  passage  of  the  injection  from  the  left  renal  vein  downward  through  the  ova- 
rian vein,  which  was  as  large  as  my  little  ringer.  Vide  Boston  Medical  and  Surgical  Journal, 
Vol.  96.  I  subsequently  found  that  this  condition  had  been  described  in  Richet's  Anatomic 
Medico-Chirurgicale. 

*  Edinburgh  Medical  Journal,  October,  1878. 


60  Frozen  Sections  of  a  Child. 

the  left  the  top  of  the  great  trochanter  appears.  Its  position  shows 
that  the  leg  had  rolled  outward  as  the  body  lay  on  its  back  to  be  frozen. 
The  pyriformis,  in  two  parts,  is  seen  on  the  right.  The  great  sciatic 
nerve,  which  leaves  the  pelvis  below  it,  appears  in  front  of  it.  On  the 
left,  where  the  plane  is  lower,  this  nerve  has  already  made  its  way  out- 
ward, so  as  to  lie  behind  the  ischium.  The  lower  branch  of  the  great 
or  superior  gluteal  nerve  is  seen  on  both  sides.  The  main  trunk  leaves 
the  pelvis  above  the  pyriformis ;  it  then  divides  into  two  branches,  of 
which  the  lower  may  be  seen  more  distinctly  on  the  right  side  tending 
toward  the  space  between  the  gluteus  medius  and  minimus. 

The  right  hip-joint  is  opened  so  high  up  that  but  a  very  small 
piece  is  taken  from  the  head  of  the  femur.  Curiously  enough,  this 
plate  shows  the  three  centres  of  ossification  of  the  acetabulum ;  that 
of  the  ilium,  which  is  the  highest  on  the  right,  those  of  the  pubes  and 
ischium  on  the  left.  The  socket  is  not  thoroughly  solidified  till  the 
seventeenth  or  eighteenth  year. 


PLATE  XV. 

THIS  section  is  about  2.2  ctm.  below  the  last.  It  passes  just  be- 
low the  symphysis  in  front,  and  misses  by  a  very  little  the  tip 
of  the  coccyx.  These  two  points,  therefore,  are  about  on  a  level,  if  the 
section  is  straight.  There  is,  however,  a  suspicion  that  it  may  slant  a 
little  backward.  The  tuberosities  of  the  ischia  with  the  pieces  of  the 
pubes  map  out  the  lateral  outlines  of  the  pelvis,  which  appears  triangu- 
lar. If  the  section  had  been  a  little  higher,  so  as  to  strike  the  tip  of 
the  coccyx  and  the  great  sacro-sciatic  ligament,  it  would  have  been 
irregularly  diamond-shaped.  As  it  is,  we  see  the  obturator  internus  on 
either  side,  in  its  case  formed  by  the  obturator  membrane  and  the  ob- 
turator fascia ;  and  in  the  middle  the  urethra,  vagina,  and  rectum,  en- 
closed by  muscle  which  appears  to  be  the  lower  part  of  the  levator  ani. 
On  either  side  of  this  is  the  fat  of  the  ischio-rectal  fossa,  which  runs 
up  between  the  levator  and  the  obturator  fascia,  and  is  continuous 
below  with  the  fat  of  the  thighs  and  buttocks.  The  coccygeus,  which 
runs  from  the  spine  of  the  ischium  to  the  side  of  the  coccyx,  is  in  the 
same  plane  as  the  levator  ani,  and  what  in  the  male  is  called  the  leva- 
tor  prostatse,  and  in  the  female  runs  to  the  sides  of  the  vagina,  is 
really  a  part  of  the  same. 

We  will  now  follow  the  rectum  from  its  beginning,  opposite  the 
left  sacro-iliac  synchondrosis,  which  appears  in  PLATE  XIII.  It  then 
sweeps  downward,  backward,  and  to  the  right,  frequently,  at  least, 
crossing  the  middle,  and  then  describing  another  curve  with  its  con- 
vexity to  the  right,  resumes  its  median  position.  PLATE  XIV.  shows 
the  last  mentioned  curve.  On  the  left  is  seen  a  sharp  fold  formed  by 
the  bowel  which  falls  on  the  line  of  the  section,  below  it  the  rectum 
expands  into  a  pouch  opposite  the  last  piece  of  the  sacrum.  The 
rectum  then  runs  forward  and  at  last  turns  distinctly  downward  and 
backward.  This  last  curve  exists  in  both  sexes,  and  it  is  very  im- 
portant that  it  should  not  be  forgotten  when  introducing  instruments. 


62  Frozen  Sections  of  a  Child. 

PLATE  XV.  shows  the  rectum  at  the  beginning  of  the  last  curve  and 
below  the  expansion  which  it  presented  at  the  level  of  the  preceding 
plate.  The  folds  of  the  mucous  membrane  of  the  rectum  are  mostly 
vertical  near  the  anus,  this  plate  shows  a  well-marked  anterior  one  ; 
higher  up  they  are  transverse  or  oblique.  The  external  sphincter 
deserves  its  name,  not  only  because  it  is  below  the  internal,  but  be- 
cause it  surrounds  it  also.  The  fibres  of  the  levator  ani  reach  the 
gut  at  the  upper  border  of  the  external  sphincter  and  mingle  with 
those  of  that  muscle.  Some  8  ctm.  above  the  anus,  there  is  very 
commonly  a  thickening  of  the  circular  muscular  fibres,  called  the  third 
sphincter.  It  is  of  little  consequence  and  does  not  deserve  the  atten- 
tion it  has  received.  The  mechanism  of  defecation  is  probably  pretty 
much  as  follows :  The  faeces  accumulate  in  the  sigmoid  flexure,  only 
a  small  part  descending  into  the  rectum  between  operations,  except 
in  cases  of  habitual  constipation.  When  the  mass  passes  into  the 
rectum  in  sufficient  quantity,  the  need  of  an  evacuation  is  felt,  but  the 
process  is  started  by  the  voluntary  muscles,  such  as  the  diaphragm 
and  those  of  the  abdomen  which  compress  the  abdominal  contents. 
This  compression  is  increased  by  the  contraction  of  the  levator  ani, 
which  at  the  same  time  tends  to  pull  open  the  anus.  The  sphincters 
yield  before  the  pressure.  Just  how  great  a  share  of  the  work  is 
done  by  the  muscles  of  the  intestine  proper  can  hardly  be  ascertained. 
It  is  probable,  however,  that  their  assistance  is  necessary  to  com- 
pletely empty  the  rectum.  Doubtless  sometimes  they  play  the  chief 
part,  and  sometimes  a  very  subordinate  one.  The  upper  part  of  the 
rectum  has  a  true  mesentery,  which  permits  moderate  displacement. 
It  has  been  demonstrated  that  the  whole  hand  can  be  introduced  into 
the  rectum,  and  also  that  it  had  much  better  not  be,  unless  the  infor- 
mation to  be  gained  is  of  sufficient  value  to  justify  risking  the  patient's 
life  to  obtain  it.  A  wedge-shaped  space  between  the  lower  parts  of 
the  rectum  and  vagina,  which  bend  respectively  backward  and  for- 
ward, is  filled  in  part  by  the  sphincter  muscles  and  the  remainder  by 
areolar  tissue.  This  is  the  perinseum.  The  urethra  is  seen  just  in 
front  of  the  vagina. 

The  right  femur  is  struck  at  the  great  trochanter.  The  lowest 
part  of  the  cavity  of  the  joint  is  opened  on  that  side,  but  on  the  left  the 
cut  passes  lower,  a  little  above  the  trochanter  minor.  The  psoas  and 
iliacus,  now  united,  are  seen  on  both  sides,  on  the  left,  just  above 
their  insertion.  They  lie  in  front  of  the  hip-joint,  and  send  some 


Frozen  Sections  of  a  Child,  63 

fibres  to  the  capsule,  which  is  thus  drawn  out  of  the  way  by  the  same 
muscle  that  flexes  the  thigh.  A  bursa  is  placed  on  the  anterior  sur- 
face of  the  capsule,  which  sometimes  opens  into  the  joint.  Pus  from 
a  psoas  abscess  can  in  this  way  enter  its  cavity.  The  views  of  the 
muscles  are  very  nearly  the  same  on  both  sides,  the  chief  difference 
being-  that  much  more  of  the  vastus  externus  is  seen  on  the  left.  The 
gluteus  maximus  and  the  tensor  vaginae  femoris  are  seen  inserted  into 
the  fascia  lata,  a  part  of  which  passes  uninterruptedly  from  the  crest 
of  the  ilium  to  the  tibia.  The  rectus  lies  beside  the  tensor,  and  the 
sartorius  is  seen  in  front.  On  the  left  leg  the  last  overlaps  the  femoral 
vessels,  which  lie  on  the  pectineus,  the  adductor  longus  being  between 
the  latter  and  the  median  line.  The  obturator  externus  can  be  easily 
identified  on  both  sides  by  its  relation  to  the  obturator  membrane. 
Behind  it  is  seen  the  quadratus  femoris,  running  from  the  tuberosity 
of  the  ischium  to  the  femur.  The  great  sciatic  nerve  lies  between  the 
quadratus  and  the  gluteus  maximus  in  the  space  between  the  tuber- 
osity and  the  trochanter.  The  remainder  of  the  muscular  mass  be- 
tween the  pelvis  and  femur  belongs  to  the  adductor  group,  but  as 
often  happens,  the  divisions  are  so  irregular  that  the  individual  mus- 
cles cannot  be  certainly  distinguished.  The  femoral  vessels  are 
named  on  the  right  side  and  require  no  comment.  On  the  left  the 
section  passes  below  the  origin  of  the  profunda,  and  consequently 
the  relations  are  less  simple.  The  femoral  vein  has  already  passed 
behind  the  artery.  The  profunda  artery  and  vein  are  situated  on 
their  outer  side.  The  external  circumflex  artery  is  seen  winding 
round  the  femur  between  the  iliacus  and  the  rectus. 


INDEX, 


Aorta,  p.  19 

arch  of,  20 
division  of,  5 1 
Artery,  carotid,  9,  12 
creliac,  36 
iliac,  51 

pulmonary,  19,  20,  21 
subclavian,  12 
Axilla,  17 


Bladder,  57 

displacement  of,  59 


Caecum,  46 

Chassaignac,  tubercle  of,  7 
Colon,  40,  41,46,47,  54 
Conus  arteriosus,  23 
Costal  cartilages,  15 


Defecation,  mechanism  of,  62 
Diaphragm,  action  of,  32 
Duodenum,  40 


Fallopian  tubes,  58 
Fascia,  cervical,  9,  12 

lumbar,  47 
Fossa,  ischio-rectal,  59,  61 


Heart,  23,  28 


Kidney,  39,  42 


Ligament,  coronary,  of  liver,  36 
sacro-sciatic,  59 
suspensory,  of  diaphragm,  13 
Liver,  35 
Lung,  apex  of,  1 1 

extra  lobe  of,  24 
fissure  of,  24 
lower  border  of,  3 1 
root  of,  2 1 


Mediastinum,  anterior,  15 
posterior,  21 

Membrane,  costo-coracoid,  13 

Mesentery,  42 

Muscle,  abdominal,  42 
deltoid,  13 
erector  spinae,  43 
levator  ani,  61 
psoas,  54 
scalenus,  anterior,  1 1 

minor,  12 

serratus  magnus,  14 
sphincter  ani,  62 
sterno-mastoid,  8 
trapezius,  14 


Nerve,  cervical,  8 
lumbar,  45 
phrenic,  8,  12,  17 
pneumogastric,  9,  17 
recurrent  laryngeal,  8,  12 
sacral,  53 

Nipple,  23 


66 


Index. 


(Esophagus,  course  of,  16 

end  of,  31 
Omentum,  cavity  of,  37,  41 

gastro-splenic,  34 

great,  41 
Ovaries,  55 


Pelvis,  inclination  of,  53 

Pericardium,  19,  29 

Perinaeum,  62 

Peritoneum  of  bladder,  58,  59 
colon,  41 
liver,  36 
spleen,  34 
rectum,  59 

Petit,  triangle  of,  43 

Pleura,  15,  24,  31,  32,  39 

Pylorus,  37 


Rectum,  61 

Respiration,  mechanism  of,  32 
Rib,  length  of  twelfth,  32 
Ribs,  relations  to  vertebrae,  1 1 


Sacrum,  54 

Scapula,  13 

space  beneath,  17 

Sheath  of  carotid,  9 

Sigmoid  flexure,  54 

Spigelius,  lobe  of,  37 

Spinal  cord,  45 

Spine,  cervical  region  of,  7 
curves  of,  49,  50 
dorsal  region  of,  23 


Spine,  lumbar  region  of,  41 

proportions  of,  50 
Spleen,  33,  34 
Sternum,  27 

position  of  top  of,  1 1 
Stomach,  37 
Suture,  neuro-central,  7 


Thoracic  duct,  15 

Thorax,  diameters  of,  15,  23 

Thymus,  15 

Thyroid,  8 

Trachea,  division  of,  15 


Umbilicus,  45 
Ureter,  51,  58 
Uterus,  58 


Valve,  aortic,  19,  24 
Eustachian,  28 
mitral,  24 
pulmonary,  19,  24 
of  renal  veins,  39 
tricuspid,  24,  28 
Varicocele  in  the  female,  59 
Vein,  jugular,  9 
portal,  39 
pulmonary,  21 
Vena  azygos,  21,  25 

cava  inferior,  28,  36 
superior,  16 


Winslow,  foramen  of,  37 


14  DAY  USE 

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